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Thursday, April 30
 

9:30am EDT

Resident Presentation - Alexis Titus
Thursday April 30, 2026 9:30am - 9:50am EDT
Athena D

Moderators
BW
Presenters
avatar for Alexis Titus
Evaluators
AB
Thursday April 30, 2026 9:30am - 9:50am EDT
Athena D
  Internal Medicine (IM), Baptist Health Princeton Hospital
  • global Y

9:50am EDT

Comparing the efficacy and safety of sotalol and dofetilide for maintenance of normal sinus rhythm at a community health system
Thursday April 30, 2026 9:50am - 10:10am EDT
Athena C
Comparing the efficacy and safety of sotalol and dofetilide for maintenance of normal sinus rhythm at a community health system Abigail Millsaps, Caitlin Casper, Dustin Bivins Northeast Georgia Medical Center – Gainesville, GA 
Background: Atrial fibrillation (AF) occurs when inappropriate electrical currents cause the atria to beat out of sync with the ventricles, creating the hallmark irregularly irregular heart rhythm. The risk of developing AF increases with age and structural heart damage, making AF a significant cause of morbidity and mortality worldwide. AF, if left untreated, can lead to cardiomyopathy, heart failure, and thromboembolism.  

Sotalol and dofetilide are class III antiarrhythmic drugs used for pharmacologic cardioversion to normal sinus rhythm (NSR) in patients who have atrial fibrillation (AF) or atrial flutter. These agents act on potassium-gated channels in myocardial cells to delay repolarization, prolong the action potential duration, and increase the effective refractory period (ERP). An increase in ERP extends the amount of time that the myocyte cannot be stimulated to fire another action potential, thus leading to a decrease in the incidence of arrhythmogenicity. However, this mechanism of action increases the risk of excessive QT (QTc) prolongation, which can result in torsades de pointes (TdP) or significant ventricular arrhythmias. Therefore, manufacturer labeling and treatment guidelines recommend initiating these medications in a hospital setting with continuous cardiac monitoring. 

There is only one randomized controlled trial directly comparing sotalol and dofetilide. The EMERALD trial, conducted in 1999, compared the safety and efficacy of dofetilide and sotalol to placebo for initial cardioversion from AF to NSR and found 29.5% of patients given dofetilide and 5.9% given sotalol converted into NSR without needing direct current cardioversion (DCCV). Researchers also found 71% of patients who converted to NSR and received dofetilide maintained NSR at 6 months compared to 59% who received sotalol. Researchers reported three cases of TdP, all in the dofetilide group. 

Purpose: The purpose of this study was to determine if sotalol or dofetilide is more efficacious at maintaining NSR at 6 months post-cardioversion in patients with AF/a-flutter. 

Methods: This was a retrospective chart review to determine the percentage of patients in NSR six months post-cardioversion either pharmacologically or via DCCV after being loaded inpatient with dofetilide or sotalol. The study population included adults ≥18 years old at Northeast Georgia Health System (NGHS) between to January 1, 2022 to August 31, 2025 who were hospitalized with AF or a-flutter, completed inpatient loading with sotalol or dofetilide, achieved NSR prior to discharge either pharmacologically or via DCCV, and were continued on the selected treatment at discharge. Patients were excluded if they had a historical use of dofetilide or sotalol, concurrent use of other antiarrhythmic medications, baseline contraindications, documented non-adherence to study medications, history of ventricular arrhythmias, or were part of a vulnerable population. Authors used chi-squared analysis to evaluate primary and secondary endpoints. 

Results: Between January 1, 2022 and August 31, 2025, 57 of 335 patients on sotalol and 17 of 53 patients on dofetilide met inclusion criteria. Baseline characteristics were similar between groups. We found no statistically significant difference in normal sinus rhythm at 6-months between sotalol and dofetilide (84.2% vs 82.4%; p = 0.557). There were no statistically significant differences in incidence of TdP or the percentage of patients requiring DCCV prior to discharge (76.5% vs 91.2%; p = 0.116). 

Conclusion: Based on these findings, there is no difference between sotalol and dofetilide at maintaining NSR at 6 -months. Only one occurrence of TdP was detected in the sotalol group, and the dofetilide group had a lower percentage of patients requiring DCCV before discharge; however, these were not statistically significant. Limitations of this study included its retrospective nature, small sample size, and reliance on provider documentation. 



Moderators
DK
Presenters
avatar for Abigail Millsaps

Abigail Millsaps

PGY-1 Resident, Northeast Georgia Medical Center
Evaluators
avatar for Allie Hale

Allie Hale

Clinical Pharmacist and Residency Program Director, Parkridge Health System
Thursday April 30, 2026 9:50am - 10:10am EDT
Athena C
  Internal Medicine (IM), Northeast Georgia Medical Center
  • global Y

9:50am EDT

Pharmacist-Led Calcium Replacement in Trauma Patients - Aileen Jimenez
Thursday April 30, 2026 9:50am - 10:10am EDT
Athena A
Poster Abstract Title: Pharmacist-Led Calcium Replacement in Trauma Patients
Primary Author: Aileen Jimenez
Contact: [email protected]
Co Authors: Heather Wilson and Madeline Mitchell
Background: Blood product administration has been associated with hypocalcemia in trauma patients receiving massive transfusion protocol (MTP) due to the binding of calcium by citrate. Calcium plays an important role in cardiac contractility and associated cardiac output. It also serves as a cofactor for vitamin K dependent clotting factors in the coagulation cascade; therefore, hypocalcemia is associated with increased mortality in trauma patients given its ability to potentiate coagulopathy, acidosis, and hypothermia. The purpose of this project was to evaluate the impact of standardized, pharmacist-led calcium replacement on hypocalcemia within 36 hours of administration of blood.
Methods: This is an IRB-reviewed, determined exempt, retrospective chart review from July 1, 2024 to February 28, 2026. Adult trauma patients, 18 years or older, who received two or more units of blood within a 24-hour period, and were subsequently admitted to an ICU were included. Data points include volume of blood products received, type and dose of calcium product received, timing of first basic metabolic panel (BMP) or arterial blood gas (ABG) after receipt of blood products, ionized calcium, serum calcium, and/or corrected calcium, and occurrence of hypo-/hypercalcemia. The primary outcome of this study was incidence of hypocalcemia within 36 hours the blood transfusion event. Secondary outcomes included achievement of normocalcemia within 36 hours of the blood transfusion event, continued normocalcemia at 72 hours, time between pRBC administration and calcium replacement, time between pRBC administration and first normalized calcium, percentage of patients with hypocalcemia who received calcium within 36h, and in-hospital mortality.
Results: Overall, 47 patients were included: 30 patients in the pre-group and 17 in the post-group. Baseline characteristics were similar between groups except for volume of fresh frozen plasma (FFP) and cryoprecipitate received (p<0.05). There was a statistically significant difference in the primary outcome of hypocalcemia within 36 hours in the pre-group vs post-group, respectively (90.0% vs 58.8%; Fisher's Exact OR: 0.1587; 95% CI (Corrected): [0.0416, 0.7630]; p=0.0232].. Additionally, there was a statistically significant difference in achievement of normocalcemia within 36 hours (55.6% vs 20.0% ; [OR: 0.2000 95% CI (Corrected): [0.0481, 1.1689] p<0.05) and time between pRBC administration and calcium replacement (9.6 hours v 5.8 hours; [median difference -3.79; 95% CI: [-10.71, -1.23]; p<0.05]). Overall, calcium was replaced more frequently in the pre-group compared to the post-group, but this difference was not statistically significant (56.7% vs 47.1% [OR 0.6797; 95% CI [0.2150, 2.2158]; p=0.5583).
Conclusion: The results suggest that the implementation of a pharmacist-led calcium replacement protocol resulted in less hypocalcemia at 36 hours; however, these results may be influenced by calcium being normal at baseline in the post-group. While pharmacist-led calcium replacement was also associated with a significantly lower time to calcium replacement, this did not result in quicker resolution of hypocalcemia. Limitations of this research include a small sample size, retrospective nature, potential for calcium receipt prior to ICU admission, and lack of differentiation between whole blood and pRBC. Future studies assessing a larger group would be beneficial to more clearly delineate the role of pharmacist-led calcium replacement on calcium levels in trauma patients.
Moderators
avatar for Aayush Patel

Aayush Patel

Clinical Pharmacy Specialist, Emergency Medicine, Piedmont Columbus Regional Midtown
Presenters
avatar for Aileen Jimenez
Evaluators
avatar for Abbi Rowe

Abbi Rowe

Director of Pharmacy, AdventHealth
Thursday April 30, 2026 9:50am - 10:10am EDT
Athena A
  Internal Medicine (IM), Cone Health
  • global Y

11:00am EDT

Evaluation of Pharmacist Impact on Inpatient Glycemic Management
Thursday April 30, 2026 11:00am - 11:20am EDT
Athena D
Background: Diabetes mellitus and hyperglycemia affect 25% to 40% of hospitalized patients and are associated with prolonged hospital stay, increased infections, and mortality. The 2026 American Diabetes Association (ADA) Standards of Care recommend insulin initiation for persistent hyperglycemia ≥180 mg/dL, with glycemic targets of 100-180 mg/dL for noncritically ill patients and 140-180 mg/dL for critically ill patients. The Centers for Medicare & Medicaid Services (CMS) tracks severe glucose excursions (≥300 mg/dL and ≤40 mg/dL) as electronic clinical quality measures (eCQMs) under the Hospital-Acquired Condition Reduction Program (HACRP). These thresholds represent the more extreme glycemic events that CMS tracks for regulatory reporting and payment penalties, distinguishing them from the broader ADA clinical classification.  Effective this year, hospitals are required to track and report eCQMs related to hyperglycemia and hypoglycemia with financial penalties for non-compliance. Additionally, these metrics may become visible in CMS and other quality measurement systems to increase public transparency in regard to inpatient glucose control.  Multiple studies have demonstrated that pharmacist interventions can improve glycemic control and reduce hypoglycemic events. The purpose of this study was to assess the impact of pharmacy involvement in glycemic monitoring within our facility’s inpatient population.

Methods: This single-center, retrospective, comparative study evaluated glucose levels in patients ≥18 years who were admitted to a community hospital. Glucose levels drawn during continuous insulin infusions were excluded. The pre-intervention group (December 1, 2024–February 28, 2025) was compared to the post-intervention group (December 1, 2025–February 28, 2026) following protocol implementation and pharmacist education. Patients were identified using automated electronic health record (EHR) alerts that flagged patients who met predefined glycemic criteria. Hyperglycemia alerts are generated when blood glucose exceeds 300 mg/dL on a single occurrence or exceeds 180 mg/dL on two occasions within 24 hours. Hypoglycemia alerts are generated for any blood glucose value <70 mg/dL. Pharmacists reviewed flagged patients' A1c, insulin regimens, glucose trends, nutritional status, renal function, and steroid use before providing recommendations to providers. Primary outcomes included the proportion of glucose measurements ≥300 mg/dL and ≤40 mg/dL. Secondary outcomes included intermediate ranges: ≥180 to <250 mg/dL, ≥250 to <300 mg/dL, and >40 to ≤70 mg/dL. The study was powered to detect a 10% relative reduction in severe hyperglycemia (≥300 mg/dL) at 80% power. Statistical significance was assessed using chi-square tests, with p < 0.05 considered significant.

Results: A total of 74,060 blood glucose measurements were analyzed in the pre-intervention period compared to 67,682 measurements in the post-intervention period. There was no statistically significant difference among baseline characteristics between the two groups. The proportion of severe hyperglycemic measurements (≥300 mg/dL) decreased significantly from 3.19% to 2.94% (ARR 0.25%; p = 0.007). The proportion of severe hypoglycemic measurements (≤40 mg/dL) showed no significant change (0.16% vs 0.15%; ARR 0.01%; p = 0.77). Significant reductions were observed in measurements ≥180 to <250 mg/dL (17.20% vs 14.84%; ARR 2.36%; p < 0.001) and ≥250 to <300 mg/dL (4.46% vs 3.80%; ARR 0.66%; p < 0.001). Level 1 hypoglycemia (>40 to ≤70 mg/dL) showed no difference (1.55% vs 1.66%; ARR −0.11%; p = 0.09).

Conclusions: Implementation of a glycemic monitoring protocol with pharmacist review was associated with significant reductions in severe and intermediate hyperglycemic levels without increasing the incidence of hypoglycemia. These findings support pharmacist involvement in improving glucose control in an inpatient setting. Future directions include the development and implementation of a pharmacist-driven glucose management protocol within our facility. Further evaluation would need to be done to assess patient-level outcomes such as length of stay, infection rates, and 30-day readmissions.
Moderators
avatar for Jessica Ringler
Presenters
avatar for Cortney Anderson

Cortney Anderson

PGY-1 Pharmacy Resident, AdventHealth
Evaluators
KL
Thursday April 30, 2026 11:00am - 11:20am EDT
Athena D
  Internal Medicine (IM), AdventHealth Redmond
  • global Y

11:00am EDT

Incidence of Bleeding in Patients Receiving Parenteral Anticoagulation and Apixaban Therapy for VTE Treatment
Thursday April 30, 2026 11:00am - 11:20am EDT
Athena C
Title: Incidence of Bleeding in Patients Receiving Parenteral Anticoagulation and Apixaban Therapy for VTE Treatment

Primary: Ashley Hannah, [email protected]
Secondary: Sara Anne Meyer, Lilia Macias, Evaline Inigo, Sarah Lopez

Background: The purpose of this study is to evaluate the association between apixaban dosing and inpatient bleeding in patients treated for venous thromboembolism following initial parenteral anticoagulation. In the inpatient setting, patients with venous thromboembolism are often initiated on parenteral anticoagulation before being transitioned to an oral anticoagulant such as apixaban. This study also aimed to evaluate whether the duration of parenteral anticoagulation was associated with initiation of reduced-dose apixaban. Understanding the factors associated with treatment decisions and clinical outcomes is critical, particularly as bleeding remains a significant complication of anticoagulant therapy.

Methods: A retrospective, randomized controlled trial was conducted involving 289 subjects at St. Joseph’s/Candler Health System from September 2024 to August 2025. Participants received parenteral anticoagulation with either standard heparin or enoxaparin, along with an oral agent. Participants received either 5 mg or 10 mg of apixaban directly following parenteral anticoagulation. This study included patients admitted for a hospital stay that were diagnosed with a venous thromboembolism within twenty-four hours of admission and received treatment with apixaban following parenteral anticoagulation. Participants with a prior history of venous thromboembolism, previous long-term therapeutic anticoagulation with apixaban for three months or severe renal dysfunction were not included. Participants were also excluded if they required anticoagulation therapy plus dual antiplatelet therapy for other indications, or thrombolytic therapy. However, participants on thrombolytic therapy undergoing catheter directed thrombolysis were not excluded.
The primary endpoint of the study was the number of bleeding events documented. Secondary endpoints included the number of patients presenting with first recurrent venous thromboembolism within six months of starting apixaban therapy, confirmed by physician documentation; assessment of severity of illness and its impact on treatment duration, evaluation of total duration of parenteral anticoagulation and its association with initiation of full versus reduced doses of apixaban therapy and lastly, identifying prescriber characteristics and practice settings associated with each treatment approach.

Conclusion: In summary, in this study no statistically significant differences were observed in bleeding events, hemoglobin decline or recurrence rates within six months of therapy between patients initiated on apixaban 5 mg in comparison to 10 mg. Prescribing patterns favored the initiation dose of 10 mg following parenteral anticoagulation for venous thromboembolism. The full dose of 10 mg appeared to be favored among the nine prescriber groups evaluated. Among patients that experienced a bleeding event, hemoglobin decrease greater than 3g/dL or recurrence within six months, apixaban 10 mg was most commonly prescribed.
  
Moderators
avatar for Eric Marr

Eric Marr

PGY1 Residency Program Director, Baptist Health Lexington
Dr. Marr graduated with a Bachelor’s degree from Western Kentucky University before obtaining his PharmD and MBA from the University of Kentucky. Dr. Marr completed a PGY1 pharmacy residency at Baptist Health Lexington and joined the organization as a clinical pharmacist following... Read More →
Presenters
AH
Evaluators
avatar for Erin Pace

Erin Pace

Ambulatory Care Pharmacist, KFHP1Kaiser Foundation Health Plan of Georgia (Managed Care)PGY1
Erin Pace, PharmD, BCACP, CDCES is an Ambulatory Care Clinical Pharmacy Specialist at Kaiser Permanente Georgia. She received her Doctor of Pharmacy from the University of Maryland, Baltimore and completed a Pharmacy Practice Residency at Kaiser Permanente, Santa Clara in San Jose, California. She is a Certifie... Read More →
Thursday April 30, 2026 11:00am - 11:20am EDT
Athena C
  Internal Medicine (IM), Candler Hospital
  • global Y

11:20am EDT

Management of Lipid-Lowering Therapy for Hospitalized Patients with Acute Coronary Syndrome (ACS)
Thursday April 30, 2026 11:20am - 11:40am EDT
Athena C
Abstract
Purpose/Background: Effective lipid management is a cornerstone of secondary prevention in patients with Acute Coronary Syndromes (ACS). The 2025 Guideline for the Management of Patients with ACS emphasizes obtaining a baseline lipid profile on admission, initiating or continuing high-intensity statin therapy during hospitalization, and considering early initiation of non-statin therapies for high-risk patients. Despite these recommendations, adherence to guideline-directed lipid management remains variable. Previous studies suggest baseline lipid panels are not consistently obtained, statins may be underutilized or prescribed at suboptimal intensities, and follow-up lipid testing is often missed. These gaps may delay achievement of lipid targets and increase the risk of recurrent cardiovascular events. This pharmacy project assessed lipid management practices for ACS patients at Huntsville Hospital and guided development of targeted pharmacy interventions to enhance adherence and optimize inpatient lipid care.

Methodology: A single-center, institutional review committee–approved pre-post analysis was conducted in patients hospitalized with acute coronary syndromes (ACS). A random sample of patients admitted between January 2025 and September 2025 with a documented ACS diagnosis was included in the pre-intervention cohort. Patients were excluded if they had a prior history of ACS or incomplete data. A pharmacy-driven intervention was implemented, consisting of targeted education for transitions of care (TOC) pharmacists and promotion of pharmacist-led discharge optimization. A post-intervention cohort was identified using the same inclusion and exclusion criteria, with the additional requirement of a documented TOC discharge note. The primary endpoints were (1) the proportion of patients with a baseline lipid panel obtained within 48 hours of admission and (2) the proportion of patients discharged on optimized guideline-directed lipid-lowering therapy. Baseline demographics and lipid management variables were collected from the electronic medical record. Descriptive statistics were used for analysis.

Results: A total of 250 patients were included in the pre-intervention cohort and 47 patients in the post-intervention cohort. A baseline lipid panel was obtained in 93.6% of patients pre- and post-intervention. Guideline-directed lipid-lowering therapy at discharge improved from 79.2% to 87.2% post-intervention (absolute increase 8.0%), while non-adherence decreased from 20.8% to 12.8%. Pharmacist interventions were documented in 19.6% of post-intervention cases and included contacting providers to recommend addition of non-statin therapy for patients on high-intensity statins with LDL-C >70 mg/dL.

Conclusion: A pharmacy-driven intervention was associated with improved adherence to guideline-directed lipid management in patients hospitalized with ACS. While baseline lipid panel acquisition was high, improvements in discharge therapy optimization were observed. These findings support the role of pharmacist involvement and targeted interventions in improving lipid management in this high-risk population.
Moderators
avatar for Eric Marr

Eric Marr

PGY1 Residency Program Director, Baptist Health Lexington
Dr. Marr graduated with a Bachelor’s degree from Western Kentucky University before obtaining his PharmD and MBA from the University of Kentucky. Dr. Marr completed a PGY1 pharmacy residency at Baptist Health Lexington and joined the organization as a clinical pharmacist following... Read More →
Presenters
avatar for AnnMarie Garcia

AnnMarie Garcia

PGY-1 Pharmacy Resident, Huntsville Hospital
Evaluators
avatar for Erin Pace

Erin Pace

Ambulatory Care Pharmacist, KFHP1Kaiser Foundation Health Plan of Georgia (Managed Care)PGY1
Erin Pace, PharmD, BCACP, CDCES is an Ambulatory Care Clinical Pharmacy Specialist at Kaiser Permanente Georgia. She received her Doctor of Pharmacy from the University of Maryland, Baltimore and completed a Pharmacy Practice Residency at Kaiser Permanente, Santa Clara in San Jose, California. She is a Certifie... Read More →
Thursday April 30, 2026 11:20am - 11:40am EDT
Athena C
  Internal Medicine (IM), Huntsville Hospital
  • global Y

12:00pm EDT

 Fall Occurrences in Relation to Psychotropic Medications: Association with Polypharmacy and Anticholinergic Burden - Brie Levy
Thursday April 30, 2026 12:00pm - 12:20pm EDT
Athena C

Moderators
avatar for Eric Marr

Eric Marr

PGY1 Residency Program Director, Baptist Health Lexington
Dr. Marr graduated with a Bachelor’s degree from Western Kentucky University before obtaining his PharmD and MBA from the University of Kentucky. Dr. Marr completed a PGY1 pharmacy residency at Baptist Health Lexington and joined the organization as a clinical pharmacist following... Read More →
Presenters
avatar for Brie Levy

Brie Levy

PGY1 Pharmacy Resident, Parkridge Health Systems
Graduated from ETSU Bill Gatton College of Pharmacy. Current PGY1 pharmacy resident at Parkridge Medical Center in Chattanooga, TN. Will be doing a PGY2 in palliative care and pain management at TVHS in Murfreesboro, TN.
Evaluators
avatar for Erin Pace

Erin Pace

Ambulatory Care Pharmacist, KFHP1Kaiser Foundation Health Plan of Georgia (Managed Care)PGY1
Erin Pace, PharmD, BCACP, CDCES is an Ambulatory Care Clinical Pharmacy Specialist at Kaiser Permanente Georgia. She received her Doctor of Pharmacy from the University of Maryland, Baltimore and completed a Pharmacy Practice Residency at Kaiser Permanente, Santa Clara in San Jose, California. She is a Certifie... Read More →
Thursday April 30, 2026 12:00pm - 12:20pm EDT
Athena C
  Internal Medicine (IM), Parkridge Health System
  • global Y

12:20pm EDT

Evaluation of Chromium Picolinate for Blood Glucose Control in Critically Ill Patients
Thursday April 30, 2026 12:20pm - 12:40pm EDT
Athena C
Evaluation of Chromium Picolinate for Blood Glucose Control in Critically Ill Patients
Christopher Stone, Richard Lane, Jared Briones 
AdventHealth Apopka

Background: Glycemic control is a cornerstone in the management of critically ill patients in the intensive care unit (ICU), as both hyper- and hypo-glycemia are associated with increased morbidity and mortality. Dysglycemia in critical illness is multifactorial, resulting from stress‑mediated neuroendocrine activation, inflammatory cytokine release, multiorgan dysfunction, and rapidly changing nutrition requirements. In recognition of adverse outcomes associated with dysglycemia, current ADA guidelines recommend targeting blood glucose levels between 140-180 mg/dL in critical illness. Chromium is a trace mineral involved in macronutrient metabolism, with studies in the outpatient setting indicating potential benefits for insulin sensitivity and glycemic control. Despite these findings, evidence supporting chromium supplementation in critically ill populations remains absent. This study aims to evaluate the effects of chromium picolinate on blood glucose management of critically ill subjects.

Methods: This was a retrospective chart review conducted within the AdventHealth Central Florida Division hospital system. Subjects were included if they were admitted from January 1st, 2022, to December 31st, 2025, age greater than 18 years, admitted to the ICU, diagnosed with type 2 diabetes mellitus or had an A1c of 6.5% or greater, and received continuous infusion insulin. Subjects were excluded if they were diagnosed with type 1 diabetes mellitus, received renal replacement therapy, or had documented chromium use prior to admission. The primary outcome was improved glycemic control, defined as a reduction in total daily insulin requirements of at least 15 units. Secondary outcomes included 30-day all-cause mortality, time to target glucose range (<180 mg/dL), hospital length of stay, ICU length of stay, and rate of adverse drug events.

Results: A total of 90 subjects were included, 45 in each group. Improved glycemic control occurred in 31% (14/45) of the chromium group compared to 13% (6/45) in the control (p-value=0.043). Analyzing the secondary outcomes, hours to target blood glucose range (<180 mg/dL) was 14 and 4 (p-value= 0.035) for the chromium and non-chromium groups respectively. There were no differences between additional outcomes including 30-day mortality, 30-day all cause readmission, hospital length of stay, ICU length of stay, and adverse drug events. Chromium was associated with decreased insulin utilization of 17.8 units compared to an increase of 22.4 units in the non-chromium group by day 3 of treatment (p-value< 0.001).

Conclusion: In critically ill patients with hyperglycemia, chromium picolinate supplementation was associated with a significant reduction in insulin utilization. No differences in adverse event rate were observed between the intervention and control group. These results indicate that chromium supplementation in critically ill patients may improve glycemic control. Limitations include the retrospective study design, lack of chromium level evaluation and the ability to identify an appropriate comparator. Further prospective studies are recommended to further explore the potential benefits of chromium on glycemic control in the critically ill.
 
Email [email protected]

Moderators
avatar for Eric Marr

Eric Marr

PGY1 Residency Program Director, Baptist Health Lexington
Dr. Marr graduated with a Bachelor’s degree from Western Kentucky University before obtaining his PharmD and MBA from the University of Kentucky. Dr. Marr completed a PGY1 pharmacy residency at Baptist Health Lexington and joined the organization as a clinical pharmacist following... Read More →
Presenters
avatar for Christopher Stone

Christopher Stone

PGY-1 Resident, AdventHealth
Evaluators
avatar for Erin Pace

Erin Pace

Ambulatory Care Pharmacist, KFHP1Kaiser Foundation Health Plan of Georgia (Managed Care)PGY1
Erin Pace, PharmD, BCACP, CDCES is an Ambulatory Care Clinical Pharmacy Specialist at Kaiser Permanente Georgia. She received her Doctor of Pharmacy from the University of Maryland, Baltimore and completed a Pharmacy Practice Residency at Kaiser Permanente, Santa Clara in San Jose, California. She is a Certifie... Read More →
Thursday April 30, 2026 12:20pm - 12:40pm EDT
Athena C
  Internal Medicine (IM), AdventHealth Apopka
  • global Y

1:50pm EDT

Assessing Adherence and Outcomes of Tafamidis and Vutrisiran in Patients with Cardiac Amyloidosis in a Rural Setting
Thursday April 30, 2026 1:50pm - 2:10pm EDT
Athena D
Authors: Amanda Dunlap, Dillion Frazier, and Cy Sims

Background: Tafamidis and vutrisiran are novel therapeutics shown to improve mortality rates and reduce hospitalization among cardiac amyloidosis patients. However, these medications are associated with substantial costs and prescribing challenges. Considering the high cost, lack of data in a rural healthcare system, and the increasing role of pharmacists in specialty pharmacies, there is a significant administrative interest in gaining a better understanding of the impact these medications have within our community. This project investigated the real-world adherence and outcomes of tafamidis and vutrisiran in a rural setting.

Methods: Tafamidis patients were identified using reports from Therigy. Reports included new starts of tafamidis from January 1, 2022-July 31, 2025, pharmacy turnaround times, and missed doses reported during follow-up. Vutrisiran patients were identified from Soarian Financials by filtering patients who received a prescription for vutrisiran from June 1, 2025-July 31, 2025. Patient charts were reviewed and followed for 6 months prior to treatment initiation and 6 months after the first prescription. The primary outcome of the study was to determine adherence to tafamidis and vutrisiran. Adherence was defined for tafamidis based on pharmacy dispensing records used to calculate the medication possession ratio greater than 80% signified adherence. Adherence for vutrisiran was based on documentation of administration in the patient medical record within 7 days of the next scheduled dose. Secondary outcomes were cardiovascular related hospital admission rates within the same patient 6 months pre-and post-drug initiation, the time from receiving the prescription to dispensing, the number of patients converted from tafamidis to vutrisiran, discontinuation of therapy as documented in the medical record or no fills within 60 days for tafamidis or a missed scheduled injection for vutrisiran, and insurance coverage.

Results: Of 153 patients included in the tafamidis group, 142 patients (92.8%) were found to be adherent. 11 patients (7.2%) were nonadherent with MPR score ranging from 66%-78%. In the vutrisiran group 4 of 13 patients were found to adherent, 7 were nonadherent as they did not receive a dose within 7 days post next scheduled dose, and 2 unable to obtain as the prescription was transferred to a different facility. Vutrisiran administration timing between doses ranged from 90-109 days for the 8 patients who received more than 1 dose, and 1 patient receiving 3 doses. Cardiovascular-related hospital admission rates were similar in the pretreatment group 9.8% vs 7.7% (tafamidis vs vutrisiran) while posttreatment admissions were higher in the vutrisiran group 13% vs 30%. The average time from receiving a prescription for tafamidis to the medication being dispensed from the pharmacy was 4.5 days and 32.2 days for vutrisiran. 13 tafamidis patients were additionally prescribed vutrisiran, and 3 patients were converted from tafamidis to vutrisiran. 7 tafamidis patients discontinued therapy while 3 vutrisiran patients discontinued. 152 patients in the tafamidis group had insurance coverage while 1 patient received 340b pricing. All vutrisiran patients had insurance coverage.

Conclusion: Tafamidis demonstrated high adherence rates, 92.8% of patients achieving a medication possession ratio ≥80, and had short pharmacy turnaround times. The findings highlight important adherence and operational challenges associated with specialty drugs especially in a rural setting. While also demonstrating the importance of specialty pharmacists optimizing access, minimizing delays, supporting adherence, and coordinating care for these patients.
Moderators
avatar for Molly Thompson

Molly Thompson

PGY1 Residency Program Director, HCA Healthcare Trident Hospital
Presenters
AD

Amanda Dunlap

PGY1 Pharmacy Resident, John D. Archbold Memorial Hospital
Evaluators
avatar for Naomi Yates

Naomi Yates

Manager, Clinical Pharmacy Services, KFHP - Kaiser Foundation Health Plan of Georgia (Ambulatory)PGY2
Thursday April 30, 2026 1:50pm - 2:10pm EDT
Athena D
  Internal Medicine (IM), John D. Archbold Memorial Hospital
  • global Y

1:50pm EDT

Impact of a Clinical Pharmacist Workflow Change on Heart Failure Readmissions
Thursday April 30, 2026 1:50pm - 2:10pm EDT
Parthenon 2
Title: Impact of a Clinical Pharmacist Workflow Change on Heart Failure Readmissions  
 
Authors: Sean Ramoso, Kathrina Gonzales Raymundo, Natalie Ortiz-Gratacos, Richard Lane, Nicholas Mastromarino, Tracey Dobbs 
Contact: [email protected]
 
Background:  
Heart failure (HF) is a complex clinical syndrome and a leading cause of morbidity and mortality in the United States.1,2 Hospital readmissions due to HF are associated with increased costs and continue to be a growing health and economic burden.2,3 The American Heart Association estimates that the total costs of HF will increase from $31 billion in 2012 to $70 billion in 2030.4 To reduce HF readmissions, studies have evaluated the implementation of HF-focused multidisciplinary teams and observed reductions in 30-day HF readmission rates. These initiatives focused on transitions of care interventions such as telephone consultations, clinic follow-ups, and comprehensive patient education.  Pharmacists can play a key role in these multidisciplinary teams through optimization of pharmacological guideline-directed medical therapy (GDMT) as recommended by the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA) Guidelines for the Management of Heart Failure. Further studies examining the impact of pharmacy-led interventions on HF readmissions and patient outcomes will be beneficial to identify the pharmacist’s role on the multidisciplinary team. 
 
Methods:  
A single-center, retrospective, chart review was conducted at AdventHealth Apopka between December 23, 2025 to March 30, 2026. A clinical pharmacist workflow change was implemented, where pharmacists completed HF-focused admission and discharge medication reconciliation reviews aimed at optimizing pharmacological GDMT per the 2022 AHA/ACC/HFSA Guidelines for the Management of Heart Failure. Patients were included if they were 18 years or older, had a diagnosis of HF, and had a HF-focused admission medication reconciliation completed by a pharmacist. Patients were excluded if they were pregnant, had a history of a heart transplant, had a scheduled heart transplant at the time of the index visit, had a diagnosis of dementia, or were discharged to hospice. The primary outcome of this study was the incidence of 30-day cardiovascular (CV)-related readmission rates, based on the index hospital discharge date. Secondary outcomes included 30-day all-cause readmission, inpatient length of stay (LOS), and the incidence of HF GDMT optimization defined as a dose titration, addition/resumption, or discontinuation of a GDMT drug class. 
 
Results: 
At the time of data analysis, the HF-focused pharmacist intervention group consisted of 52 patients who had 30-day readmissions data available. A comparator group of 52 patients admitted during the same study period without a HF-focused pharmacist intervention was utilized. For the primary outcome of 30-day CV-related readmission, this occurred in 9/52 (17.3%) patients in the intervention group and 11/52 (21.2%) patients in the comparator group (p = 0.495). For the secondary outcome of 30-day all-cause readmission, this occurred in 17/52 (32.7%) of patients in the intervention group and 16/52 (30.8%) of patients in the comparator (p = 0.946). The mean length of stay in the intervention group was 4.64 +/- 3.79 days compared with 2.94+/- 4 days in the comparator group (p = 0.056). HF GFMT optimization occurred in 41/52 (77.4%) patients in the comparator group and 28/52 (52.8%) of patients in the comparator group (p = 0.013). 
 
Conclusion: 
A HF-focused pharmacist workflow change was associated with a numerical, but not statistically significant, reduction in 30-day CV-related readmissions. This pharmacist workflow change was also associated with a significant increase in the incidence of HF GDMT. Key barriers to GDMT optimization included weekday-only coverage, challenges in reliably identifying eligible HF patients, competing staffing responsibilities, and variable acceptance of GDMT recommendations which were often deferred to outpatient follow-up. Next steps should focus on expanding pharmacist coverage to increase completion of HF-focused medication reconciliations, refining the HF patient identification report, implementing strategies to improve GDMT recommendation uptake, and evaluating outcomes over a longer timeframe with a larger sample. 
 
References 
  1. Heidenreich, P. A., et al. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18). https://doi.org/10.1161/cir.0000000000001063 
  1. Urbich, M., Globe, G., Pantiri, K. et al. A Systematic Review of Medical Costs Associated with Heart Failure in the USA (2014–2020). PharmacoEconomics 38, 1219–1236 (2020). https://doi.org/10.1007/s40273-020-00952-0 
  1. Kwok, C. S., et al. (2021). Cost of inpatient heart failure care and 30-day readmissions in the United States. International Journal of Cardiology, 329, 115–122. https://doi.org/10.1016/j.ijcard.2020.12.020 
  1. Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the Impact of Heart Failure in the United States: A Policy Statement From the American Heart Association. Circulation: Heart Failure. 2013;6(3):606-619. doi:https://doi.org/10.1161/hhf.0b013e318291329a 
 

Moderators
avatar for Lucy Crosby

Lucy Crosby

Medication Policy and Compliance Pharmacist, AUMC2Augusta University Medical Center/University of Georgia College of Pharmacy PGY1

Presenters
avatar for Sean Ramoso

Sean Ramoso

PGY1 Pharmacy Resident at AdventHealth Apopka
Evaluators
avatar for Sarah Frye

Sarah Frye

PGY2 Critical Care Residency Program Director, Spartanburg Medical Center (Critical Care)PGY2
Sarah Frye, PharmD, BCCCP is the Clinical Pharmacy Specialist for Surgical / Trauma Critical Care and Residency Program Director for the PGY2 Critical Care Residency Program at Spartanburg Medical Center in Spartanburg, South Carolina. Dr. Frye completed her Doctor of Pharmacy degree... Read More →
Thursday April 30, 2026 1:50pm - 2:10pm EDT
Parthenon 2
  Internal Medicine (IM), AdventHealth Apopka
  • global Y

1:50pm EDT

Impact of Antimicrobial Stewardship Provider Education on Patients with Community-Acquired and Aspiration Pneumonia
Thursday April 30, 2026 1:50pm - 2:10pm EDT
Athena C
Authors: Dalia Chamma, Colin Busbee, Holly Mclean, Desmond Durham 

Purpose/Background: The initial recommendation for empiric anaerobic coverage in aspiration pneumonia was made in the 1970s, following the identification of anaerobic isolates in multiple studies. This was likely due to poor isolation techniques and the collection of microbiologic specimens later in the course of disease, including after abscesses, necrotizing pneumonia, or empyema had developed. The purpose of this study is to evaluate whether a guideline-based educational intervention directed at prescribers reduces empiric anaerobic coverage in adults hospitalized with community-acquired pneumonia (CAP) or aspiration pneumonia without abscess or empyema, and to assess clinical outcomes, including C. difficile infections, days of therapy with empiric anaerobic coverage, and hospital length of stay.  
 
Methodology: This study will employ a retrospective chart review of patients to evaluate provider prescribing practices pre- and post-education. The educational intervention material is a guideline-based, one-page summary of the American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) 2019 CAP recommendations regarding the appropriate use of empiric anaerobic coverage in aspiration pneumonia. The educational material will highlight the indications for which anaerobic coverage is appropriate, emphasize that the management of aspiration pneumonia follows standard CAP treatment, and summarize the literature that the guidelines are based upon. Educational materials will be presented to the Antimicrobial Stewardship (AMS) Committee and to appropriate service-line leadership committees for review and approval prior to electronic distribution to clinicians. Data will be collected and evaluated from Slicer Dicer reports and the hospital’s electronic records for retrospective reviews of pre- and post-intervention. The primary objective is to compare the proportion of patients with community-acquired or aspiration pneumonia who receive empiric anaerobic coverage before versus after implementation of guideline-based provider education. Secondary objectives include comparing anaerobic antibiotic days of therapy, length of stay, time to clinical stability, and C. difficile infection 30-day readmission rates in patients with aspiration or community-acquired pneumonia in the pre- and post-intervention arms. 

Results: In progress. 

Conclusions: In progress. 
Moderators
AP
Presenters
avatar for Dalia Chamma
Evaluators
avatar for Kayla Brown

Kayla Brown

PGY-1 Residency Program Director, East Alabama Medical Center
Thursday April 30, 2026 1:50pm - 2:10pm EDT
Athena C
  Internal Medicine (IM), CaroMont Regional Medical Center
  • global Y

2:10pm EDT

Impact of Time to Positive Blood Culture and Time to Definitive Antimicrobial Therapy on Mortality in Intensive Care Unit Patients with Bacteremia
Thursday April 30, 2026 2:10pm - 2:30pm EDT
Athena H
Impact of Time to Positive Blood Culture and Time to Definitive Antimicrobial Therapy on Mortality in Intensive Care Unit Patients with Bacteremia
Nicole Rios Serrano, Lena K. Tran, Christopher Lloyd
AdventHealth Kissimmee – Kissimmee, FL

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

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

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

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

Kellie Ball

PGY2 Ambulatory Care Coordinator, University of Tennessee Medical Center
Hi! My name is Kellie Ball and I am currently the Coordinator for the PGY2 Ambulatory Care program at University of Tennessee Medical in Knoxville, TN. I graduated with my PharmD and Masters of Public Health from Samford University in Birmingham, AL.
Presenters
avatar for Nicole Rios Serrano

Nicole Rios Serrano

PGY-1 Pharmacy Resident, AdventHealth


Evaluators
avatar for Kelvin Gandhi

Kelvin Gandhi

Infectious Diseases Clinical Pharmacist, AdventHealth Daytona Beach
Thursday April 30, 2026 2:10pm - 2:30pm EDT
Athena H
  Internal Medicine (IM), AdventHealth Kissimmee

2:30pm EDT

Evaluation of Atrial Fibrillation Post-Left Ventricular Assist Device - Glennessa Hodge
Thursday April 30, 2026 2:30pm - 2:50pm EDT
Athena A
Evaluation of Atrial Fibrillation Post-Left Ventricular Assist Device Authors: Glennessa Hodge, Anna Crider, Brian Tran, Kiara Patino, Eleanor Schoen, Mahmoud H. Abdou Background  
Atrial fibrillation is a common postoperative complication following ventricular assist device (VAD) placement contributing to significant morbidity. Beta-blockers are considered first-line agents for the prevention of postoperative atrial fibrillation (POAF); however, many VAD patients are not on beta-blockers preoperatively due to relying on inotropes. Amiodarone is commonly used to reduce the incidence of POAF; however, its role and optimal duration in VAD recipients remains unclear. Current guidelines offer varying recommendations on dosing and therapy duration, ranging from 4 to 12 weeks. This study aims to identify the incidence of POAF, assess the use of amiodarone in management, and explore the impact on patient outcomes.    
Methods  
This study was a retrospective chart review of patients who received a left ventricular assist device (LVAD) at Emory University Hospital (EUH) or Emory Saint Joseph’s Hospital (ESJH) from October 1st, 2022, to March 31st, 2025. 
The primary outcome of this study was to identify the incidence of atrial fibrillation from LVAD implant to post-operative day 90. Secondary objectives included 90-day rehospitalization, postoperative total length of stay, thromboembolic or stroke incidence, and death. Amiodarone dosing was up to provider discretion as there were no protocols in place during this study time frame. Descriptive statistics include mean, median, or mode as appropriate to assess the primary and secondary outcomes. A multivariate regression analysis was conducted to compare POAF and non-POAF patients to identify associated risk factors.   
Results
POAF was seen in 71 out of 119 (37.5%) participants. 90-day all cause and arrhythmia related rehospitalization were 69 (36%) and 12 (6%) out of 190 respectively. The median postoperative length of stay was 22 in the total population, 24 (IQR 19-38.5) amongst POAF patients, and 20 (IQR 16-25.5) for non-POAF patients. 90-Day mortality was 18 (9%) out of 190, 6 from the POAF group and 12 from the non-POAF group. Antiarrhythmics used to treat POAF were amiodarone (35.3%), digoxin (4.2%), and dofetilide (0.5%). Majority of POAF patients were treated with intravenous amiodarone and then transitioned to oral amiodarone 200 mg daily at discharge. 43% of patients discharged on amiodarone did not have their amiodarone plan readdressed within 90 days post discharge. Of the 73 out of patients who received amiodarone prophylaxis for a median of 14 days, 44 (60.2%) did not experience POAF (OR = 1.77, 95% CI = 0.64 - 2.14).  
Conclusion
The POAF incidence is consistent with the 15-50% reported from previous studies. The patient population had common risk factors for POAF, including older age (≥ 60, 42.8%), male sex (77%), hypertension (76%), diabetes (46%), and non-ischemic cardiomyopathy (75%). Amongst patients that experienced POAF, approximately 89.5% were managed with amiodarone at a variety of doses. 56% of patients were on amiodarone prior to admission and 7% were intentionally placed or continued amiodarone for prophylaxis per documentation. 
Analysis of all patients that received amiodarone within the 72 hours immediately prior to LVAD implantation, revealed a greater percentage of patients who got prophylaxis did not experience POAF, however this study was not adequately powered to detect significant difference in outcomes. 90-day outcomes between patients that did and did not experience POAF were similar, however, the POAF group had a longer length of stay at 24 days and a higher percentage of cardiac related readmission compared to the non-POAF group.  
This study suggests a possible benefit in amiodarone prophylaxis in patients with high risk features or history of atrial fibrillation prior to LVAD. The exact dosing regimen and duration is still to be explored, but our study found that higher cumulative amounts of amiodarone did not show better outcomes.
Moderators
avatar for John Puryear
Presenters
avatar for Glennessa Hodge

Glennessa Hodge

PGY1 Acute Care Resident, Emory Healthcare
Hello, I am Glen a current PGY1 pharmacy resident at Emory University Hospital. I received my PharmD from Mercer University College of Pharmacy and will be continuing my training next year as a PGY2 in internal medicine at East Tennessee State University Bill Gatton College of Pharmacy... Read More →
Evaluators
avatar for Katherine Fuller

Katherine Fuller

Clinical Pharmacy Specialist --Hepatology
Clinical pharmacy specialist at Emory University Hospital Midtown serving Hepatitis B and C patient populations through the Emory Center for Viral Hepatitis. Emory Midtown PGY1 Pharmacy Practice (Specialty Focused) Residency Director.
Thursday April 30, 2026 2:30pm - 2:50pm EDT
Athena A
  Internal Medicine (IM), Emory University Hospital
  • global Y

2:30pm EDT

Evaluation of Initial Dose of Nitroglycerin for Acute Heart Failure Exacerbation
Thursday April 30, 2026 2:30pm - 2:50pm EDT
Athena C
Evaluation of Initial Dose of Nitroglycerin for Acute Heart Failure Exacerbation
Authors: Amaury Santiago Malave, Christopher Lloyd, Lena Tran 
Background Nitroglycerin, a vasodilator, administered as an intravenous (IV) bolus at doses between 400 to 800 mcg and infusions of 100-200 mcg/min have shown to rapidly decrease preload, afterload, and improve myocardial oxygen supply in patients with pulmonary edema and acute decompensated heart failure. Literature suggests these higher IV doses of nitroglycerin have led to reduced intensive care unit (ICU) admissions and intubations; however, there is currently limited guidance for an initial nitroglycerin bolus dose or infusion rate, leading to frequent underdosing.  The objective of this study is to evaluate the use of nitroglycerin for acute heart failure exacerbations and to assess the significance of nitroglycerin doses on ICU admission and need for mechanical ventilation.

Methods This study was reviewed by the local investigational review board and deemed a quality improvement project. A retrospective data analysis was conducted on adult patients presenting to AdventHealth Central Florida hospitals between August 6, 2023 and August 29, 2025 with acute heart failure exacerbation requiring intravenous nitroglycerin and non-invasive positive airway pressure (NIPAP).  
Patients were stratified according to nitroglycerin initiation strategy: 1) higher-intensity nitroglycerin (HIN) which included receiving an IV nitroglycerin bolus and/or initiation of continuous infusion at ≥ 100 mcg/min. 2) lower-intensity nitroglycerin (LIN) which consisted of starting a continuous infusion at < 100 mcg/min with no bolus.  
Data was collected from the electronic health record and included baseline demographics, nitroglycerin bolus dose (if administered), initial infusion rate, and maximum infusion rate. Safety data included baseline and repeated measurements of systolic blood pressure, heart rate, respiratory rate, and oxygen saturation. The primary outcome was ICU admission. Secondary outcomes included hospital length of stay, endotracheal intubation, incidence of hypotension, infusion duration, time to NIPAP discontinuation, and change in vital signs two hours after infusion initiation. Continuous variables were analyzed using means with standard deviations and medians with interquartile ranges, as appropriate, and compared using Student’s t-test or the Mann-Whitney U test.  

Results A total of 181 patients met inclusion criteria, with 99 managed using HIN and 82 managed using a LIN. ICU admission occurred in 59.6% of patients in the higher-intensity group compared to 68.2% in the lower-intensity group, though this difference did not reach statistical significance (p = 0.226). Rates of endotracheal intubation (2.02% vs 4.88%, p = 0.285) and hypotension (4.04% vs 3.66%, p = 0.894) were similar between groups. Hospital length of stay and time to NIPAP discontinuation were not significantly different. The HIN group received significantly greater initial and maximum infusion rates (p < 0.001 for both comparisons). Median infusion duration was significantly shorter in the higher-intensity group (3 vs 4 hours, p=0.033). Changes in systolic blood pressure, respiratory rate, heart rate, and oxygen saturation were comparable between groups. 

Conclusion In this retrospective analysis of patients with acute heart failure exacerbations requiring NIPAP, a higher-intensity nitroglycerin initiation strategy was associated with lower ICU admission and intubation rates compared to a lower-intensity approach, although these differences did not reach statistical significance. Of note, this higher-intensity strategy was not associated with increased hypotension or adverse effects and resulted in a shorter median infusion duration. 
While the study was not powered to detect small differences in clinical outcomes, the observed trends suggest that more aggressive upfront nitroglycerin dosing may be both feasible and well tolerated in appropriately selected patients. These findings support the need for prospective, adequately powered studies to further evaluate dose thresholds for nitroglycerin strategies that can meaningfully reduce ICU admission and respiratory deterioration in acute heart failure exacerbations.
Moderators
AP
Presenters
AS
Evaluators
avatar for Kayla Brown

Kayla Brown

PGY-1 Residency Program Director, East Alabama Medical Center
Thursday April 30, 2026 2:30pm - 2:50pm EDT
Athena C
  Internal Medicine (IM), AdventHealth Kissimmee
  • global Y

2:30pm EDT

Inpatient Pharmacist-led Penicillin Allergy Delabeling (iPPADL)
Thursday April 30, 2026 2:30pm - 2:50pm EDT
Athena D
Inpatient Pharmacist-led Penicillin Allergy Delabeling (iPPADL)
Authors: Caleb Gosnell, Benjamin Britt, Vince Buttrick, Erik Turgeon at Lexington Medical Center
Background/Purpose: Reports of penicillin allergies are common, as many as 25% of patients have a penicillin allergy in their medical record. Most of these patients have mild reactions, such as urticaria. Patients with a remote history of allergy from childhood are <5% likely to have a retained allergy to penicillins. Recent studies have identified pharmacist-led allergy de-labeling approaches with a focus on antimicrobial stewardship have positive outcomes on alternative antibiotic utilization, Clostridioides difficile infection rates, inpatient length of stay, and patient costs. Barriers to traditional approaches include the need for either skin testing supplies with appropriate training or additional stock of oral amoxicillin. In a cost-saving approach, it may be efficacious to use patient medical history and interviewing to assess the possibility of de-labeling.
Methodology: This was a pre- and post-intervention review of inpatient encounters at a single-center 607-bed community teaching hospital. The intervention for this study was the implementation of a pharmacist-led penicillin allergy delabeling protocol. Pharmacists determine eligibility by reviewing PEN-FAST assessment results, reported allergy reactions, and previous inpatient penicillin/aminopenicillin administrations. Patients with a PEN-FAST score of 0 with a non-immune mediated reaction, such as nausea, qualified for de-labeling.  Patients with a PEN-FAST score of 0 or 1, with a minor immune-mediated reaction, such as urticaria, were further evaluated for prior inpatient administrations of a penicillin or aminopenicillin. If tolerated, the patient qualified for delabeling. All patients received bedside education of the process of qualifying for delabeling and required verbal consent to remove the allergy from the medical chart.  The pre-intervention group consisted of inpatients with a penicillin allergy and PEN-FAST assessment between July 1, 2025 – October 31, 2025. The post-intervention group consisted of inpatients with a penicillin allergy and PEN-FAST assessment between November 1, 2025 – February 28, 2026. Outcomes were then assessed manually by the investigator through electronic health record (EHR )-generated data and manual chart review.
Results: During the pre-intervention phase, a total of 1,912 admissions had a labeled penicillin allergy and 215 had a PEN-FAST score reported with 75 patients eligible for delabeling. In the post-intervention phase, a total of 1,527 admissions had a penicillin allergy. Of those admissions, 232 had a PEN-FAST score reported. Seventy-nine patients were eligible for delabeling with 25 qualifying by a non-immune reaction and 54 with a penicillin class administration. Piperacillin/tazobactam was the major contributor with 38 eligibilities. A total of 18 patients were delabeled with most (14) qualifying via penicillin class administrations. Three patients refused the intervention, and two patients were relabeled at a subsequent outpatient encounter.
Conclusions: A pharmacist-led allergy delabeling protocol based upon chart review and patient interview is a low-cost alternative to skin testing, though its success is highly limited by workflow time constraints, altered patient mentation, EHR reporting logistics, and patients located on floors without decentralized pharmacists. Another potential limiting factor is that this study did not account for patients with short length of stays that could further decrease the time available for assessment and intervention. Future considerations are a more direct identification process through pharmacist notification rather than a passive report that must be actively reviewed. Additionally, expanding the protocol to include conversations with medical decision-makers for patients with chronic altered mental status. In the future, the protocol will shift to a stewardship initiative to capture more patients, improve decentralized communication of opportunities, and potential expansion to oral challenge in patients who are low risk for a true allergy without qualifying administrations.

Moderators
avatar for Molly Thompson

Molly Thompson

PGY1 Residency Program Director, HCA Healthcare Trident Hospital
Presenters
avatar for Caleb Gosnell

Caleb Gosnell

PGY1 Pharmacy Resident, Lexington Medical Center
Evaluators
avatar for Naomi Yates

Naomi Yates

Manager, Clinical Pharmacy Services, KFHP - Kaiser Foundation Health Plan of Georgia (Ambulatory)PGY2
Thursday April 30, 2026 2:30pm - 2:50pm EDT
Athena D
  Internal Medicine (IM), Lexington Medical Center
  • global Y

2:50pm EDT

Evaluating Methotrexate Effectiveness for Ectopic Pregnancy Management in Obese Patients
Thursday April 30, 2026 2:50pm - 3:10pm EDT
Athena C
Background: Ectopic pregnancy is a potentially life-threatening condition commonly managed with methotrexate in hemodynamically stable patients without absolute contraindications. Although methotrexate dosing is calculated using body surface area, the optimal weight-based strategy in obese patients remains uncertain. Historically, Northside Hospital Atlanta, Cherokee, and Forsyth utilized adjusted body weight for dosing due to concerns about toxicity. However, questions regarding potential underdosing and reduced efficacy prompted a transition to total body weight–based dosing on May 6, 2025. This study compares treatment success and adverse drug reactions between adjusted body weight and total body weight methotrexate dosing strategies in hemodynamically stable obese patients with tubal ectopic pregnancy.

Methods: This retrospective cohort study evaluated the safety and efficacy of single-dose intramuscular methotrexate dosed at 50 mg/m2 in obese patients diagnosed with tubal ectopic pregnancy before and after implementation of total body weight–based dosing. Obesity was defined as a total body weight greater than 130% of ideal body weight. The primary outcome was treatment success, defined as resolution of ectopic pregnancy without additional methotrexate doses or surgical intervention. Secondary outcomes included adverse drug reactions. Eligible patients were ≥18 years old and received methotrexate for tubal ectopic pregnancy. Patients with relative contraindications to methotrexate such as, β-hCG >5,000 mIU/mL, ectopic mass >4 cm, or fetal cardiac activity, were included. Data collected from electronic medical records included demographics, baseline labs, initial β-hCG levels, ultrasound findings, need for additional methotrexate dosing, surgical intervention, and documented adverse events. Comparative analyses were performed within and between adjusted and total body weight dosing groups.

Results: A total of 120 women were included in the study, with 60 patients in both the pre-implementation and post-implementation cohorts. In the pre-implementation cohort, 32 patients were obese and 28 were non-obese. Treatment resolution occurred in 81.3% (26/32) of obese patients and 64.3% (18/28) of non-obese patients. Among non-obese patients, 17.9% (5/28) had pre-methotrexate β-hCG levels >5,000 mIU/mL, 7.1% (2/28) had ectopic masses >4 cm, and 0% had cardiac embryonic activity. In contrast, 0% of obese patients had β-hCG levels >5,000 mIU/mL, and none had ectopic masses >4 cm or embryonic cardiac activity. The post-implementation cohort included 37 obese and 23 non-obese patients. Treatment resolution occurred in 59.5% (22/37) of obese patients and 56.5% (13/23) of non-obese patients. Among non-obese patients, 4.3% (1/23) had pre-methotrexate β-hCG levels >5,000 mIU/mL, 0% had an ectopic mass >4 cm, and 4.3% (1/23) had cardiac embryonic activity. Among obese patients, 13.5% (5/37) had pre-methotrexate β-hCG levels >5,000 mIU/mL, 5.4% (2/37) had ectopic masses >4 cm, and 0% had cardiac embryonic activity. After accounting for relative contraindications to methotrexate administration in obese and non-obese patients within each group, there was a lower difference in resolution rates within the pre-implementation arm (obese, 81.3% vs non-obese, 76.2%) vs the post-implementation arm (obese, 66.7% vs non-obese, 57.1%)

Conclusions: In this retrospective study, adjusted resolution rates for relative contraindications showed a greater difference in success rates, favoring obese patients, in the post-implementation group compared to the pre-implementation group. Although total body weight dosing was associated with a higher frequency of adverse events, no serious adverse events were observed. These findings confirm that relative contraindications to methotrexate reduce efficacy, and further prospective studies with larger sample sizes are needed to define the optimal methotrexate dosing strategy in obese patients. Considerations for future studies include utilizing a 2-dose methotrexate regimen for patients with an initial elevated hCG, evaluating differences in success rates across obese subgroups stratified by differences in BMI, and excluding patients with relative contraindications to methotrexate.  

Moderators
AP
Presenters
avatar for David Matatov

David Matatov

David Matatov is from Atlanta, GA. He did his undergraduate studies at Georgia State University and received his Doctor of Pharmacy degree from Mercer University College of Pharmacy. David is a current PGY1 Pharmacy Resident at Northside Hospital Atlanta. Next year, David will be... Read More →
Evaluators
avatar for Kayla Brown

Kayla Brown

PGY-1 Residency Program Director, East Alabama Medical Center
Thursday April 30, 2026 2:50pm - 3:10pm EDT
Athena C
  Internal Medicine (IM), Northside Hospital
  • global Y

2:50pm EDT

Implementation of Prescriber Antibiotic Scorecards in a Rural Community Hospital
Thursday April 30, 2026 2:50pm - 3:10pm EDT
Athena D
Title: Implementation of Prescriber Antibiotic Scorecards in a Rural Community Hospital

Authors: Valeriy Shipilov PharmD, Joshua Pruitt PharmD, BCIDP

Purpose: Antimicrobial stewardship is an essential practice component in acute care settings as about 30% of all antibiotics prescribed in U.S. acute care hospitals are unnecessary or suboptimal.  Tracking and reporting of antimicrobial utilization are two core elements of stewardship programs and aid benchmarking, transparency, and accountability. Previous studies on implementation of antimicrobial utilization reports have limited data on efficacy of these interventions on prescribing trends. The purpose of this study is to implement and track the impact on provider prescribing habits in a rural community hospital.

Methods: This report was developed and implemented at a rural community hospital with an average daily census of 125. Prescriber antibiotic utilization will be tracked by determining the number of shifts worked by a prescriber and the number of broad-spectrum antibiotics prescribed in a month. Data will be tracked and analyzed with a reporting software available through the hospital's electronic health record.  Broad spectrum antibiotics will be defined as cefepime, meropenem, levofloxacin, and piperacillin-tazobactam. Broad spectrum antibiotic utilization will be reported to providers monthly as a rolling average of the number of targeted antibiotics prescribed per shift worked. Prescribers will be privately provided with their randomized identification number in an effort to blind data of their peers. 

Results: We saw a statistically significant reduction in antibiotics prescribed per shift over time after the intervention (p = 0.019). There was no trend observed that was independent of the intervention (p=0.951) and there was no statistically significant immediate effect based on the intervention (p=0.076). We did not see a statistically significant reduction in days of therapy for targeted antibiotics (p=0.191) after the implementation of the scorecard. 

Conclusions: Overall, we saw a statistically significant reduction in antibiotics prescribed per shift after the implementation of our prescribing scorecard. Although there was no effect on days of therapy, the results support the use of antibiotic scorecards as a means of tracking and reporting prescribing habits to physicians. Additionally, the reduction in use of broad-spectrum antibiotics has allowed us to meet quality goals for antibiotic prescribing, and we hope to expand the scope of the report to target reduction in days of therapy and possibly intravenous to oral switching. 

Contact Information: [email protected]
Moderators
avatar for Molly Thompson

Molly Thompson

PGY1 Residency Program Director, HCA Healthcare Trident Hospital
Presenters
avatar for Valeriy Shipilov

Valeriy Shipilov

PGY1 Pharmacy Resident, Baptist Health Deaconess Madisonville
Hello! My name is Valeriy Shipilov and I am a PGY1 Pharmacy Resident at Baptist Health Deaconess Madisonville. I completed my PharmD at Keck Graduate Institute in Southern California and have previously worked as a pharmacy Intern while I was in school. For the future, I plan on working... Read More →
Evaluators
avatar for Naomi Yates

Naomi Yates

Manager, Clinical Pharmacy Services, KFHP - Kaiser Foundation Health Plan of Georgia (Ambulatory)PGY2
Thursday April 30, 2026 2:50pm - 3:10pm EDT
Athena D
  Internal Medicine (IM), Baptist Health Deaconess Madisonville

3:10pm EDT

Characterization of Extravasation Events in Brain and Spinal Cord Injury Rehabilitation Patients
Thursday April 30, 2026 3:10pm - 3:30pm EDT
Athena J
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. 

Moderators
KN
Presenters
avatar for Muhan Wang
Evaluators
KM

Ketrin Mount

PGY1 Pharmacy Residency Program Director, James H. Quillen VA Medical Center

Thursday April 30, 2026 3:10pm - 3:30pm EDT
Athena J
  Internal Medicine (IM), Shepherd Center

3:10pm EDT

Evaluating the Impact of Empiric Anti-MRSA Therapy on Length of Stay in Patients Hospitalized with Community-Acquired Pneumonia - Jessica Giraldo
Thursday April 30, 2026 3:10pm - 3:30pm EDT
Athena C
Title: Evaluating the Impact of Empiric Anti-MRSA Therapy on Length of Stay in Patients Hospitalized with Community-Acquired Pneumonia 
Authors: Jessica Giraldo, Dina Kheir, Timmy Do
Institution: AdventHealth Central Florida Division (AH-CFD)

Background 
Community-acquired pneumonia (CAP) remains one of the leading causes of hospitalization in the United States, contributing to morbidity, mortality, and healthcare costs. The 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines recommend reserving empiric anti-methicillin-resistant Staphylococcus aureus (MRSA) therapy for patients with validated risk factors. Despite these recommendations, anti-MRSA agents are frequently initiated empirically in patients without validated risk factors. Prior studies evaluating empiric anti-MRSA therapy in CAP have primarily focused on clinical outcomes such as 30-day mortality. These studies also reported increased rates of acute kidney injury (AKI), Clostridioides difficile infection (CDI), and prolonged hospitalization with anti-MRSA therapy. This study evaluated whether empiric anti-MRSA therapy impacts hospital length of stay (LOS) among adults hospitalized with CAP in a large, multi-hospital health system.  

Methods 
This retrospective observational cohort study included adults ≥18 years admitted with a diagnosis of CAP across AdventHealth Central Florida Division (AH-CFD) hospitals between January 1, 2023 and December 31, 2024. Exclusion criteria included documented MRSA risk factors, severe immunocompromise (absolute neutrophil count <500 cells/mm³, CD4 <200 cells/mm³, or recent transplant), or ICU admission at presentation. The primary outcome was hospital LOS and secondary outcomes included 30-day all-cause mortality, 30-day hospital readmission, antibiotic-associated adverse events (e.g. AKI and CDI), and time to clinical stability.  

Results 
A total of 178 patients met inclusion criteria, including 92 patients who received empiric anti-MRSA therapy and 86 who received standard CAP therapy. Median hospital LOS was 3.15 days (IQR 2.16–4.81) in the anti-MRSA group compared with 2.79 days (IQR 1.79–4.20) in the standard-therapy group, with no statistically significant difference (p = 0.091).  

Thirty-day all-cause mortality occurred more frequently in patients receiving empiric anti-MRSA therapy compared with standard therapy (4.35% vs 2.33%; RR 1.87, 95% CI 0.35–9.95; p = 0.68). Thirty-day readmission occurred significantly more frequently among patients receiving empiric anti-MRSA therapy (15.22% vs 3.49%; RR 4.36, 95% CI 1.30–14.66; p < 0.001). Antibiotic-associated adverse events were also more common in the anti-MRSA group (5.43% vs 0%; RR 10.29, 95% CI 0.58–183.37; p = 0.06). CDI occurred in more patients of the anti-MRSA group when compared to standard-therapy patients (1.09% vs 0%; RR 2.81, 95% CI 0.12–67.98; p = 1.00). Time to clinical stability was assessable in 40 patients in each treatment group. Median time to clinical stability was 2 days (IQR 2–3; p = 0.67) in both the anti-MRSA and standard therapy groups. 

Conclusions 
Empiric anti-MRSA therapy in adults hospitalized with CAP was not associated with shorter LOS, faster clinical stability, or improved mortality. While 30-day readmission occurred significantly more frequently among patients receiving empiric anti-MRSA therapy, antibiotic-associated adverse events, AKI, and CDI were numerically higher but did not reach statistical significance. These findings support guideline recommendations to reserve anti-MRSA therapy for patients with validated risk factors and highlight opportunities for antimicrobial stewardship interventions to reduce unnecessary antibiotic exposure and improve patient safety. 

Contact Information: [email protected] 
 

Moderators
AP
Presenters
avatar for Jessica Giraldo

Jessica Giraldo

PGY1 Pharmacy Resident, AdventHealth East Orlando
Jessica Giraldo, PharmD, is a PGY-1 Pharmacy Resident at AdventHealth East Orlando. She earned her Doctor of Pharmacy degree from Lake Erie College of Osteopathic Medicine (LECOM) and plans to work as a clinical pharmacist after completing her residency.
Evaluators
avatar for Kayla Brown

Kayla Brown

PGY-1 Residency Program Director, East Alabama Medical Center
Thursday April 30, 2026 3:10pm - 3:30pm EDT
Athena C
  Internal Medicine (IM), AdventHealth East Orlando
  • global Y

3:10pm EDT

Evaluation of Discharge Medication Prescribing for Patients with Heart Failure Before and After Pharmacist Involvement 
Thursday April 30, 2026 3:10pm - 3:30pm EDT
Parthenon 2
TITLE: Evaluation of Discharge Medication Prescribing for Patients with Heart Failure Before and After Pharmacist Involvement 
AUTHORS: Uyen Nguyen, Amanda Herndon, and Christine Wong
BACKGROUND: Heart failure (HF) is a leading cause of hospital admissions and readmissions in the United States. The 2022 ACC/AHA/HFSA guidelines recommend that eligible patients with heart failure be discharged on compare guideline-directed medical therapy (GDMT) to reduce morbidity, mortality, and rehospitalization. Despite strong evidence supporting GDMT, many patients are not discharged on all recommended therapies due to system-level gaps, and unaddressed patient-specific barriers. Meta-analysis and observational studies have shown that patients who have medications reviewed by pharmacists prior to discharge are more likely to be discharged on appropriate GDMT. This study aims to assess the effect of pharmacist involvement on adherence to heart failure GDMT prescribing at discharge in a community teaching hospital.

METHODOLOGY: This single-center, comparative study received Institutional Review Board exemption. Retrospective chart review was conducted to compare GDMT prescribing at discharge for all patients with HF before and after pharmacist involvement. During the intervention period, pharmacists received education on assessing HF GDMT eligibility, identifying opportunities for initiation, and ensuring appropriate documentation of contraindications. Providers also received education on potential GDMT initiation, appropriate documentation, medication contraindications, and cost considerations.
Pharmacists reviewed medications and provided recommendations to optimize GDMT for all HF patients prior to discharge. All pharmacist interventions and documentation of contraindications were recorded. Patients who were at least 18 years of age and had a diagnosis of HF were included in the results. Patients who expired or enrolled in hospice or comfort care at any time during the study were excluded. Enrollment of 80 patients in both pre-intervention and post-intervention groups would provide 80% power to detect a 20% difference in the composite GDMT prescribing, with a significant p-value of 0.05.
The primary outcome was the percentage of patients with HF discharged on appropriate composite GDMT. Composite GDMT was defined as adherence to angiotensin-converting-enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor (ACEi/ARB/ARNi), mineralocorticoid receptor antagonists (MRA), and evidence-based beta-blockers (BB) for patients with heart failure with reduced ejection fraction (HFrEF) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) for all patients with heart failure. Secondary outcomes included the percentage of patients prescribed each individual component of GDMT at discharge, including ACEi/ARB/ARNi, BB, MRA, and SGLT2i, when indicated. Adherence was defined as recommended therapy prescribed at discharge or documented contraindications to any component of GDMT.

RESULTS: The primary outcome of composite GDMT before and after pharmacist involvement increased from 40% in the pre-intervention group to 77.5% in the post-intervention group, n= 80 in each group, p-value <0.001. Secondary outcomes showed an increase in each individual component of GDMT. Among patients with HFrEF, n = 31 in each group, prescribing rates in the post-intervention group compared to the pre-intervention group group increased as follow: ACEi/ARB ARNi from 35% to 74%, p 0.002, BB increased from 74% to 100%, p=0.003, MRA increased from 47.5% to 87%, p=0.002. Prescribing of SGLT2i for all HF patients increased from 47.5% to 78%, p<0.001.

CONCLUSIONS: Baseline findings showed significant gaps in the prescribing of GDMT or appropriate documentation of contraindications for patients with heart failure at hospital discharge, particularly with ACEi/ARB/ARNi, MRA, and SGLT2i. Improvements following pharmacist involvement suggest that targeted education, medication review, and real-time recommendations at discharge can increase adherence to evidence-based therapies. The findings highlight the benefit of pharmacist involvement to optimize GDMT, address barriers to prescribing, and improve documentation of contraindications.
Moderators
avatar for Lucy Crosby

Lucy Crosby

Medication Policy and Compliance Pharmacist, AUMC2Augusta University Medical Center/University of Georgia College of Pharmacy PGY1

Presenters
avatar for Uyen Nguyen
Evaluators
avatar for Sarah Frye

Sarah Frye

PGY2 Critical Care Residency Program Director, Spartanburg Medical Center (Critical Care)PGY2
Sarah Frye, PharmD, BCCCP is the Clinical Pharmacy Specialist for Surgical / Trauma Critical Care and Residency Program Director for the PGY2 Critical Care Residency Program at Spartanburg Medical Center in Spartanburg, South Carolina. Dr. Frye completed her Doctor of Pharmacy degree... Read More →
Thursday April 30, 2026 3:10pm - 3:30pm EDT
Parthenon 2
  Internal Medicine (IM), AdventHealth Redmond

3:40pm EDT

Factors Associated With Nocturnal Hypoglycemia In A Small Community Hospital
Thursday April 30, 2026 3:40pm - 4:00pm EDT
Athena C
Factors Associated With Nocturnal Hypoglycemia In A Small Community Hospital
Nhien Nguyen, Maggie Braxton Green, Geren ThomasArchbold Memorial Hospital - Thomasville, GA

Background/Purpose: The American Diabetes Association guideline categorizes hypoglycemia in three levels. Level one hypoglycemia is a glucose concentration of 54–69 mg/dL. Level two hypoglycemia is a glucose concentration of <54 mg/dL. Level three hypoglycemia is a severe event characterized by altered mental and/or physical functioning that requires assistance from another person for recovery, irrespective of glucose level. Nocturnal hypoglycemia is defined as glucose falling below 70 mg/dL and lasting at least 15 minutes anytime from midnight to 6-am. It is important to avoid hypoglycemia in hospitalized patients as there are complications associated with increased cost, length of stay, morbidity, and mortality. The purpose of this study is to analyze and identify risk factors associated with nocturnal hypoglycemia occurring in hospitalized patients in a rural single site hospital.  

Methodology: This was a single site, retrospective, cross-sectional study of adult hospitalized patients at a 264-bed community hospital. Data was extracted from electronic the health record and included patient’s gender, race, weight, past medical history, length of stay, renal function, A1C, glucose levels, time of episode, diet orders, medication orders, and signs and symptoms which may have occurred during nocturnal episode. Patient’s blood glucose levels were collected on admission, 24 hours prior to nocturnal hypoglycemic episode and during hypoglycemic episode. Patient’s chart was reviewed 24 hours prior from the time of the episode to identify potential causes. Primary endpoint is identifying factors potentially associated with nocturnal hypoglycemia episodes in hospitalized patients. 

Results: From January to December 2025, a total of 451 patients were identified to have a hypoglycemic episode. Exclusion criteria included patient on insulin drip during hospital stay, history of DKA and/or HHS, sleep apnea, history of cirrhosis, hepatitis B and C, adrenal insufficiency, pancreatic diseases. The most common exclusion criteria met were factors related to past medical history, insulin drip or hypoglycemic episodes did not take place during 0000-0600. These patients were then reviewed for potential risk factors that were associated with the hypoglycemic episode. Among review, the blood glucose level ranged from 10 to 69 mg/dL with average of 59 mg/dL. Level one hypoglycemia occurred 691 times while level two occurred 210 times. Of the patients who experienced nocturnal hypoglycemia, 47% had diet order for “nothing by mouth,” 33% of patients were on at least one or more beta-blocker agents, 9% were on a quinolone agent, and 34% were on at least one or more nonsteroidal anti-inflammatory drugs during their hospitalization.  

Conclusions: Nocturnal hypoglycemia can be a dangerous medical complication that can be influenced by types of diet, the use of beta-blockers, quinolones, and nonsteroidal anti-inflammatory drugs. Due to the multiple confounders associated with increased risk, a larger population with closer real time monitoring may be needed to directly correlate associated risk factors. 

Presentation Objective: Identify potential risk factors associated with nocturnal hypoglycemia occurring in hospitalized patients in a single site community hospital.
Self-Assessment:
Which of the following is the definition of nocturnal hypoglycemic per the ADA guideline?
A.Glucose level < 69 mg/dL and lasting at least 5 minutes from midnight to 0600
B.Glucose level ≤ 70 mg/dL and lasting at least 15 minutes from midnight to 0300
C.Glucose level < 70 mg/dL and lasting at least 15 minutes from midnight to 0600
D.Glucose level < 54 mg/dL and lasting at least 10 minutes from 0300 to 0600





Moderators
NH
Presenters
NN

Nhien Nguyen

Pharmacy Resident (PGY1), Archbold Memorial Hospital
Evaluators
NS
Thursday April 30, 2026 3:40pm - 4:00pm EDT
Athena C
  Internal Medicine (IM), John D. Archbold Memorial Hospital
  • global Y

3:40pm EDT

Utility of β-hydroxybutyrate as a defining criterion for diabetic ketoacidosis resolution in adults
Thursday April 30, 2026 3:40pm - 4:00pm EDT
Athena J
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] 

Moderators
RF
Presenters
avatar for Kevin Fenter

Kevin Fenter

PGY1 Pharmacy Resident, AdventHealth
Kevin Fenter, PharmD is currently a PGY1 pharmacy resident at AdventHealth Celebration. He completed his pharmacy education at the University of Florida. Following completion of his PGY1 residency year Kevin plans to pursue a clinical role ideally within the critical care realm.
Evaluators
avatar for Rachel Langenderfer

Rachel Langenderfer

Clinical Pharmacy Specialist - Residency Program Coordinator, Bon Secours St. Francis Downtown
I am a clinical pharmacy specialist at Bon Secours St. Francis Downtown Hospital, and I serve as the PGY-1 Residency Program Coordinator and the PGY-2 Internal Medicine Residency Program Director. I went to Campbell University College of Pharmacy and Health Sciences and completed... Read More →
Thursday April 30, 2026 3:40pm - 4:00pm EDT
Athena J
  Internal Medicine (IM), AdventHealth Celebration
  • global Y

4:00pm EDT

COMPARATIVE EFFECTIVENESS OF MEROPENEM VS NOVEL β-LACTAMS FOR ESBL BLOOD STREAM INFECTIONS: A RETROSPECTIVE COHORT EVALUATION Valerie Alonso, Anel Couzo, Dana Roth, Pamela Andrews, Jessica Snawerdt, Monica Cozad, Timmy Do AdventHealth Altamonte Springs- A
Thursday April 30, 2026 4:00pm - 4:20pm EDT
Athena C
Background/Purpose: 
Extended-spectrum β-lactamase (ESBL)-producing Enterobacterales bacteremia is associated with increased morbidity and mortality. Although carbapenems are considered standard therapy, their use is not always feasible in clinical practice, emphasizing the need for evidence supporting effective alternative strategies. Newer β-lactam/β-lactamase inhibitor combinations, including ceftolozane/tazobactam and ceftazidime/avibactam, demonstrate activity against ESBL-producing organisms, but comparative effectiveness remains limited.  
 
The purpose of this study was to evaluate clinical outcomes of patients with ESBL bacteremia treated with meropenem compared with ceftolozane/tazobactam, or ceftazidime/avibactam.  
 
Methodology:  
This multicenter retrospective cohort study included adult patients (≥18 years) with at least one positive blood culture for ESBL-producing Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis who received ≥48 hours of definitive monotherapy with meropenem, ceftolozane/tazobactam, or ceftazidime/avibactam. Patients were identified through electronic medical records reports across AdventHealth hospital campuses. A retrospective chart review was conducted for encounter occurring between August 1, 2022, and December 31, 2025.  
 
The primary outcome was clinical efficacy, defined as a composite of: resolution of fever by day 5, improvement in leukocytosis (white blood cell count ≤10,000/µL) by day 5, no vasopressor requirement at day 5, survival at hospital discharge or 30 days from admission, and absence of recurrent primary infection due to ESBL-producing Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis at day 5. 
 
Secondary outcomes included 14-day all-cause mortality, hospital length of stay, need for transfer to a higher level of care ≥48 hours after treatment onset, escalation or change in antimicrobial therapy, and serious adverse events such as Clostridioides difficile infection and seizures. A Desirability of Outcome Ranking (DOOR) analysis was performed to evaluate overall clinical outcomes incorporating treatment response, safety events, and mortality. 
 
Results:  
A total of 68 patients met inclusion criteria and were included across three treatment groups: meropenem (MEM, n=44), ceftolozane/tazobactam (C/T, n=10), and ceftazidime/avibactam (CZA, n=14). Baseline characteristics were generally comparable between groups, with similar illness severity based on Pitt bacteremia scores. Clinical success rates did not significantly differ between treatment groups (MEM 68.2% vs C/T 70% vs CZA 78.6%; p>0.05). No statistically significant differences were observed in recurrence of infection, 14-day all-cause mortality, hospital length of stay, transfer to higher level of care, or adverse events such as seizures. However, antibiotic change occurred significantly more often in the BL/BLI groups compared with meropenem (C/T 30%, p<0.001; CZA 21.4%, p=0.002), with most changes involving transition to meropenem therapy. DOOR analysis demonstrated similar overall patient outcomes across treatment groups without statistically significant differences.   
 
Conclusions:  
In this multicenter retrospective cohort study, meropenem and novel β-lactam/β-lactamase inhibitor agents demonstrated comparable clinical efficacy and mortality outcomes for treatment of ESBL bloodstream infections. While overall outcomes were similar, meropenem showed greater therapeutic stability, reflected by the absence of antibiotic change. Interpretation is limited by the retrospective design and small sample size, highlighting the need for larger prospective studies to better define the role of these agents in ESBL bacteremia management. 

Moderators
NH
Presenters
VA
Evaluators
NS
Thursday April 30, 2026 4:00pm - 4:20pm EDT
Athena C
  Internal Medicine (IM), AdventHealth Altamonte Springs
  • global Y

4:00pm EDT

Evaluating the Duration of Mupirocin’s Effect on Methicillin-Resistant Staphylococcus aureus Nares Polymerase Chain Reaction Validity
Thursday April 30, 2026 4:00pm - 4:20pm EDT
Parthenon 1
Background:
Mupirocin, an RNA synthetase inhibitor produced by Pseudomonas fluorescens, is widely used for empiric methicillin-resistant Staphylococcus aureus (MRSA) decolonization in hospitalized patients. MRSA nares polymerase chain reaction (PCR) testing is frequently performed on admission to guide antimicrobial therapy; however, the effect of prior mupirocin exposure on PCR detectability is not well described.
Methods:
This retrospective cohort study was conducted across Ballad Health facilities from August 2022 to July 2025. Adults aged ≥18 years with documented MRSA colonization within one year who completed a five-day mupirocin decolonization course during a prior admission and underwent MRSA nares PCR testing on readmission were included.
The primary endpoint was median time in days from mupirocin completion to repeat PCR testing, compared between PCR-positive and PCR-negative groups. Secondary endpoints included MRSA culture positivity on readmission and concordance between PCR and culture results, assessed using McNemar’s test and Cohen’s kappa.
Results:
Among 124 readmissions, 84 (68%) patients had positive and 40 (32%) had negative MRSA nares PCR results. Median time to PCR testing did not significantly differ between PCR-positive (77 days; IQR 38.3–120.8) and PCR-negative groups (52 days; IQR 26–118.5; p = 0.18).
When stratified by time since mupirocin completion, PCR positivity was 59.5% (25/42) within ≤60 days, 78.6% (22/28) at 61–90 days, 66.7% (12/18) at 91–120 days, and 69.4% (25/36) at >120 days. Differences across these intervals were not statistically significant (χ² p = 0.15).
MRSA was isolated in 11 cultures during the index admission and in 23 cultures on readmission, most commonly from wound, respiratory, and blood specimens. During the index admission, 18% (22/124) of patients with a positive PCR had a corresponding positive MRSA culture. On readmission, overall observed agreement between PCR and culture results was 52.4%, with a Cohen’s kappa coefficient of 0.20. McNemar’s test indicated statistically significant discordance between PCR and culture findings (p < 0.05), predominantly attributable to PCR-positive, culture-negative pairs.
Conclusions:
In this study, timing of prior mupirocin exposure was not associated with reduced MRSA nares PCR detectability on readmission. Although culture positivity increased on readmission, concordance between PCR and culture remained limited. Evaluation within a larger cohort is warranted.
Moderators
RP
Presenters
avatar for Robert Berger
Evaluators
SC
Thursday April 30, 2026 4:00pm - 4:20pm EDT
Parthenon 1
  Internal Medicine (IM), Johnson City Medical Center
  • global Y

4:00pm EDT

Impact of a pilot standardized, multi-preceptor approach to acute care medicine APPEs on student outcomes & preceptor satisfaction
Thursday April 30, 2026 4:00pm - 4:20pm EDT
Athena I
Background and Purpose: Increasing complexity in healthcare has led to the growth of pharmacists' clinical responsibilities, requiring a high level of adaptability and critical thinking. Therefore, pharmacy graduates need strong critical thinking and problem-solving skills to navigate complex patient care. Because of this, pharmacy school curriculum promotes critical thinking development through as case-based learning in the classroom setting, culminating with experiential learning that further emphasizes analysis and application. Previous studies have explored multi-preceptor approaches to advanced pharmacy practice experiences (APPE) to enhance student learning; however, these studies were not focused on critical thinking and had no direct evaluation of preceptor satisfaction. The purpose of this pilot study was to evaluate the impact of a standardized, multi-preceptor approach to acute care medicine APPEs on student critical thinking skills and preceptor satisfaction. 
Methods: This was an IRB-exempt, single center pilot study conducted from September 1st, 2025 to April 30th, 2026. During September 2025, a team of Acute Care Medicine APPE preceptors developed and implemented a standardized, multi-preceptor approach   consisting of eight scheduled case-based active learning sessions focused on core internal medicine topics. The sessions were designed to enhance students’ critical thinking and clinical problem-solving skills. As part of their rotation, students were given a pre- and post-rotation competency assessment consisting of sixteen multiple-choice, case-based questions aligned with content from the eight sessions (maximum score: 16). The pre- and post-rotation assessments varied slightly but tested the same core concepts. Improvement in student critical thinking was measured by the change in pre- and post-rotation assessment scores. Preceptor satisfaction was assessed using an anonymous online survey at the end of the study period, consisting of ten Likert scale and three free response questions.  All student assessment data were collected as part of routine educational activities within the rotation and analyzed in aggregate. Scores of all 4th year pharmacy students completing an Acute Care Medicine rotation in either Internal Medicine or Family Medicine at Wellstar MCG Health during the study period were included. Preceptors were included in the study if they served as the primary preceptor for at least one pharmacy student within the same timeframe. Change in assessment scores was analyzed using a paired t-test. All other results were analyzed using descriptive statistics. 
Results: Assessment data from 12 APPE students and survey responses from 6 preceptors were included in the analysis. Prior to acute care medicine rotation, the students included in the analysis had a median of 3 direct patient care APPE rotations [IQR: 2-3] and a median of 1 acute care APPE rotation [IQR: 1-2]. Average assessment scores increased significantly from pre- to post-rotation (8.08 vs 10.17, p = 0.0036). Across the 10 Likert-scale items, the majority of responses indicated agreement or strong agreement. Preceptors most strongly endorsed statements regarding team precepting effectiveness (16.7% agree, 83.3% strongly agree), student experience consistency (16.7% agree, 83.3% strongly agree), and critical thinking development (50% agree, 50% strongly agree). In free response questions, preceptors highlighted prespecified case-based discussions and collaborative scheduling as key strengths of the model. 
Conclusions: In this pilot study, 4th year pharmacy students demonstrated improved case-based assessment scores following an acute care medicine with a standardized, multi-preceptor model. This suggests that a multi-preceptor, case-based approach may support development of student critical thinking skills. Preceptors reported high satisfaction with the standardized model, with all preceptors in agreement that the acute care medicine team worked together effectively to precept students.  

Moderators
avatar for Kendall Huntt

Kendall Huntt

PGY1 Residency Program Coordinator, Emory University Hospital
Presenters
AB
Evaluators
avatar for Kendra Brookshire

Kendra Brookshire

Associate Chief, Outpatient Clinical Pharmacy Services, Birmingham VA Healthcare System
Thursday April 30, 2026 4:00pm - 4:20pm EDT
Athena I
  Internal Medicine (IM), Wellstar MCG Health/University of Georgia College of Pharmacy
  • global Y

4:20pm EDT

Evaluation of apixaban dosing strategies for venous thromboembolism in patients receiving hemodialysis
Thursday April 30, 2026 4:20pm - 4:40pm EDT
Athena C
Title: Evaluation of apixaban dosing strategies for venous thromboembolism in patients receiving hemodialysis 

Authors: Hayden Caldwell, Blake Sloan, Ryan Tilton, Ryan Imel, Grace Barr, Caitlin Hastings, & Brittney Bright

Background: Venous thromboembolism (VTE) is categorized as deep venous thromboembolism (DVT) or pulmonary embolism (PE) caused by the formation of a thrombus in the veins of the lower extremities or pulmonary arteries. Apixaban is a factor Xa inhibitor approved for the indication of VTE treatment. Apixaban is mainly metabolized by CYP3A4 with other CYP enzymes contributing to minor metabolism. Apixaban is 87% protein bound and approximately 27% renally eliminated. However, patients with end stage renal disease (ESRD) receiving hemodialysis were not included in initial trials which established dosing. Existing literature is limited regarding whether to omit or include the loading dose of apixaban (10mg twice daily for 7 days) in this patient population.  Given that a percentage of apixaban is renally cleared, there is concern regarding an increased bleed risk in patients with ESRD on HD receiving the standard loading dose.  Current clinical practice varies and may be influenced by provider preference.  

Methods: This study evaluated the safety and efficacy of the apixaban loading dose versus no loading dose in patients with ESRD on hemodialysis receiving treatment for VTE. We conducted a multi-center, retrospective cohort study at North Carolina Baptist Hospital and Atrium Health High Point Medical Center. Eligible patients included adults who have ESRD receiving hemodialysis and developed a VTE treated with apixaban from April 2024 to October 2025. Patients were excluded if they had antiphospholipid syndrome, received concurrent CYP3A4 inducers/inhibitors, received continuous renal replacement therapy, received apixaban 2.5mg, or received greater than or equal to seven days of parenteral anticoagulation prior to starting apixaban. The primary outcome was the incidence of recurrent VTE or progression of DVT to PE within 90 days after apixaban initiation. Secondary outcomes were the occurrence of major bleeding and clinically relevant non-major bleeding within 14 days of apixaban initiation defined by the International Society on Thrombosis and Haemostasis . Statistical analyses included descriptive statistics using t-test for continuous variables, Fischer’s exact test for categorical variables, and mean and interquartile range for various characteristics.  

Results: There were 30 patients included in this study, 18 patients in the apixaban load group, and 12 patients in the apixaban no-load group. The most common reason for not being included in this study was receipt of parenteral agents for greater than seven days and chronic VTE. There were more patients in the apixaban load group with liver disease with seven in the load group and one in the no load group. Overall, comorbidities were similar between the two groups except there were more patients in the load group that had liver disease with seven patients in the load group and one patient in the no load group. The primary outcome was incidence of recurrent VTE or progression of DVT to PE, which occurred in one (5.6%) patient in the apixaban load group and zero (0.0%) in the apixaban no-load group. The secondary outcome of occurrence of major bleeding within 14 days occurred in two (11.1%) patients in the apixaban load group and zero (0.0%) in the apixaban no load group. The other secondary outcome of clinically relevant non-major bleeding within 14 days occurred in one (5.6%) patient in the apixaban load group and one (8.3%) patient in the no load group.  

Conclusion: The results of this study were inconclusive due to the small sample size and low incidence of outcomes. The overall low sample size limited the ability to perform appropriate statistical analysis. The observed data showed a possible increased incidence of major bleeding events, but statistical significance is indeterminant. Further studies with larger sample sizes are needed to determine any changes needed in clinical practice.


Moderators
NH
Presenters
HC
Evaluators
NS
Thursday April 30, 2026 4:20pm - 4:40pm EDT
Athena C
  Internal Medicine (IM), High Point Medical Center, Atrium Health Wake Forest Baptist
  • global Y

4:20pm EDT

Evaluation of Phosphorus Replacement Protocol Implementation during CRRT
Thursday April 30, 2026 4:20pm - 4:40pm EDT
Athena H
Evaluation of Phosphorus Replacement Protocol Implementation during Continuous Renal Replacement Therapy (CRRT)
Emma Smits, Morgan Vincent, Mike Maccia
Cone Health at Moses Cone Hospital - Greensboro, NC

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

Emma Smits

PGY1 Pharmacy Resident, Cone Health
My name is Emma Smits, PharmD, and I am a PGY1 Pharmacy Resident at Cone Health at Moses Cone Hospital. I attended pharmacy school at the University of North Carolina at Chapel Hill. I am continuing my postgraduate training next year in the PGY2 Pediatric Pharmacy Residency Program... Read More →
Evaluators
avatar for Sarah McDaniel

Sarah McDaniel

Antimicrobial Stewardship Coordinator, Baptist Medical Center South
Thursday April 30, 2026 4:20pm - 4:40pm EDT
Athena H
  Internal Medicine (IM), Cone Health
  • global Y

4:20pm EDT

Impact of 2025 Acute Coronary Syndromes Guidelines on Prescribing Practices at a Tertiary Medical Center - Taylor Butler
Thursday April 30, 2026 4:20pm - 4:40pm EDT
Parthenon 2
Background: In February 2025, the American College of Cardiology (ACC) and American Heart Association (AHA) released updated guidelines for acute coronary syndrome (ACS) management. Key medication-related updates include a preference for ticagrelor or prasugrel over clopidogrel in patients undergoing percutaneous coronary intervention (PCI), as well as more aggressive lipid management strategies recommending the addition of non-statin therapies in patients who do not achieve recommended low-density lipoprotein cholesterol (LDL-C) targets of < 55-70 mg/dL despite maximally tolerated statin therapy. This study aims to evaluate changes in prescribing patterns following guideline release at a tertiary medical center and to identify potential barriers to adoption.
Methods: This single-center, retrospective cohort study will evaluate adult patients diagnosed with Non–ST-elevation myocardial infarction (NSTEMI) or ST-elevation myocardial infarction (STEMI) who underwent PCI between October 1, 2024 and January 31, 2025 (pre-guideline cohort), and June 1, 2025 and September 30, 2025 (post-guideline cohort). Patients requiring coronary artery bypass graft (CABG) surgery will be excluded. A three-month washout period following publication of the updated guidelines until June 1, 2025 was incorporated to allow for integration into clinical practice. Data will be abstracted from the electronic medical record (EMR) and will include patient demographics, ACS presentation, baseline laboratory values, and medication prescribing patterns, including discharge antiplatelet therapy and lipid-lowering therapy. All data will be de-identified prior to analysis. Descriptive statistics will be used to summarize baseline characteristics and prescribing patterns. Categorical variables will be compared between cohorts using chi-square analysis to evaluate differences in guideline adoption before and after publication. Statistical significance will be defined as a p-value <0.05.
Results: A total of 442 patients with STEMI or NSTEMI were screened, of whom 97 met inclusion criteria (pre-guideline cohort n=46; post-guideline cohort n=51). Baseline characteristics were generally similar between groups, although statin intolerance was more common in the post-guideline cohort (13.7% vs 2.2%, p=0.037) and oral anticoagulant use at discharge was lower (9.8% vs 26.1%, p=0.035). Appropriate P2Y12 inhibitor prescribing at discharge increased numerically following guideline publication (50% vs 56.9%), though this difference was not statistically significant (p=0.499); however, the distribution of discharge P2Y12 inhibitor selection differed significantly between cohorts (p=0.001), with increased use of prasugrel and ticagrelor and reduced use of clopidogrel post-guideline. Nonstatin lipid-lowering therapy prescribing increased from 15.2% to 23.5% (p=0.303), while appropriate statin prescribing remained high in both groups (91.3% vs 98%, p=0.129).
Conclusion: Following the 2025 ACS guideline update, prescribing patterns shifted modestly toward guideline-preferred P2Y12 inhibitors and increased use of nonstatin lipid-lowering therapies after PCI, though adoption remained incomplete and may have been influenced by factors such as baseline oral anticoagulant use and cost limitations. These findings highlight the need for continued education and targeted strategies to improve implementation of updated guideline-directed discharge therapy after PCI.
Moderators
avatar for Sheema Hallaji

Sheema Hallaji

PGY1 Residency Director, Cone Health- Alamance Regional Medical Center
Presenters
TB
Evaluators
avatar for Savannah Owen

Savannah Owen

Assistant Professor of Pharmacy Practice, South College School of Pharmacy
Savannah Owen earned her PharmD from Auburn University Harrison College of Pharmacy. Since graduating, she has completed the PGY-1 community pharmacy residency at South College School of Pharmacy in Knoxville, TN. She also completed an ambulatory care PGY-2 residency with St. Peter... Read More →
Thursday April 30, 2026 4:20pm - 4:40pm EDT
Parthenon 2
  Internal Medicine (IM), Piedmont Atlanta Hospital
  • global Y

4:20pm EDT

OPIOID UTILIZATION WITH ENHANCED RECOVERY AFTER CESAREAN DELIVERY PROTOCOL VERSUS STANDARD OF CARE
Thursday April 30, 2026 4:20pm - 4:40pm EDT
Olympia 2
OPIOID UTILIZATION WITH ENHANCED RECOVERY AFTER CESAREAN DELIVERY PROTOCOL VERSUS STANDARD OF CARE
Authors: Trace Easterling, Amanda Williams, Allison Daneault, Catherine Childre, Anna Bulman, Brianna Wheeler, Megan Missanelli, Brittney Bicksler, Francie Ruzic.

Objective: Compare opioid utilization in patients undergoing cesarean delivery with and without use of the enhanced recovery after cesarean delivery protocol.

Background/Purpose –
Cesarean delivery is the most common surgical procedure in the United States and accounts for many women’s first exposure to opioids. The Enhanced Recovery After Surgery (ERAS) Society has published guidelines for many surgical procedures, including cesarean delivery, with the goal of expediting post-surgical recovery, minimizing exposure to opioids, and improving maternal and neonatal outcomes. Until recently, only one facility within Infirmary Health System utilized a standardized Enhanced Recovery and Cesarean (ERAC) protocol. The primary aim of this study is to compare opioid utilization in patients undergoing cesarean delivery with and without use of the ERAC protocol.

Methods –
A retrospective chart review of patients at least 18 years of age undergoing cesarean delivery with ERAC protocol and without ERAC protocol across the three labor and delivery units encompassed in Infirmary Health System was conducted starting July 31, 2025 and working back in time until 150 patients in each category had been reviewed. Data collected through the electronic health record (EHR) included patient demographics, primary or repeat cesarean, scheduled or unscheduled cesarean, intraoperative and post-operative pain management modality, total morphine milligram equivalents (MMEs) post-operatively, length of hospitalization, average daily pain scores for post-operative days 1-3, and post-operative duration epidural and urinary catheterization. Discharge prescriptions were also reviewed and total MMEs of all outpatient prescriptions were recorded. Patient were excluded if they were less then 18 years old, had a complication that may have resulted in increased opioid requirements or length of stay, or had grossly incomplete chart data.

Results –
A total of 303 patients were included in the results of the study. 145 patients received the non-ERAC protocol and 158 received the ERAC protocol. The median total postoperative MMEs were lower in the ERAC arm compared to the non-ERAC study arm (22.5 vs. 86.3 p < 0.01).  Median length of stay and time to first as needed analgesic was also lower in the ERAC group compared to the non-ERAC group (Length of stay (h): 63 vs 75 p < 0.01; Time to first as needed analgesic (h): 15.8 vs. 24.6 p < 0.01). Median postoperative pain scores at day one, two, and three were also decreased in the ERAC arm (Day 1: 1 vs. 2 p < 0.01; Day 2: 2 vs. 3 p < 0.01; Day 3: 2 vs. 3 p < 0.01). For the median MMEs prescribed at discharge, patients in the ERAC group had a lower MME prescribed at discharge compared to those in the non-ERAC group. (MMEs at discharge: 112.5 vs 225 p < 0.01)

Conclusions –
Patient receiving cesarean sections in the ERAC protocol had reduced inpatient opioid requirements, a shorter length of stay, improved pain control and accelerated recovery timelines compared to those in the non-ERAC group. Mothers in the ERAC group also went longer without requesting additional analgesics and received less opioids at discharge on average. These results continue to prove positive outcomes for ERAC protocols mothers receiving cesarean sections. 

Moderators
KD
Presenters
avatar for Trace Easterling

Trace Easterling

PGY1 Resident, Mobile Infirmary
Evaluators
avatar for Marci Swanson

Marci Swanson

Clinical Pharmacist Practitioner, Carl Vinson VA Medical Center
Thursday April 30, 2026 4:20pm - 4:40pm EDT
Olympia 2
  Internal Medicine (IM), Mobile Infirmary Medical Center
  • global Y

4:40pm EDT

Association of degree of pyuria and symptomatic urinary tract infections at a community hospital
Thursday April 30, 2026 4:40pm - 5:00pm EDT
Athena C
Background/Purpose: Asymptomatic bacteriuria (ASB) is common in the general population. The Infectious Diseases Society of America (IDSA) guidelines have recommended only screening for and treating ASB in pregnant women or before an invasive urological procedure. ASB is the presence of 1 or more species of bacteria growing in the urine between (≥105 colony-forming units [CFU]/mL or ≥108 CFU/L) in the absence of signs or symptoms of a urinary tract infection (UTI). The lack of pyuria or white blood cells (WBCs) in the urine makes the diagnosis of a UTI highly unlikely. However, the presence of pyuria alone is not an indicator of a UTI. 

At CHI Memorial Hospital, when a UTI is suspected, a culture can only be ordered through a urinalysis (UA) reflex process. The urinalysis must show ≥ 20 WBCs for a culture to be performed. Anecdotally, the antimicrobial stewardship team sees a large number of urine cultures performed despite patients clinically meeting criteria for ASB. This analysis was designed to evaluate our current urinalysis WBC count threshold for reflex to urine culture with the hope of determining an optimal cutoff to decrease the overculturing of urines without significantly missing true infections. 


Methods: This will be a single-center, IRB-approved, retrospective chart review evaluating hospitalized adult patients with a urinalysis with reflex to culture order during the month of July 2025. Patients who were treated as outpatients or those presenting with long term urinary catheters (> 4 weeks) were excluded. The primary objective of this study is to determine how the degree of pyuria relates to a symptomatic UTI: sensitivity, specificity, and positive and negative predictive values will be assessed at various urinary WBC count ranges.

Results: Most patients in the study were elderly females and over 90% of the orders were from the emergency department. About one-third of the patients grew a uropathogen in culture out of the total sampled patients. Uropathogens were generally more likely to grow at increasing urine WBC count; <1% at 0-10 WBC/hpf and 11% at > 100 WBC/hpf. Sensitivity, specificity, positive and negative predictive value were calculated at different urine white blood cell cutoffs which showed that as urine white blood cell count increases, sensitivity decreases significantly from 100% to about 20%. The specificity increases as white blood cell count in the urine increases from 20% to up to 95%. The positive predictive value remains low at less than 50% for all urine white blood cell counts and the negative predictive value remains high at greater than 85% for all urine white blood cell counts. About one-third of patients each grew a uropathogen, a non-uropathogen or had no growth. Among the uropathogens, The most prevalent organism was E. coli at 47%, followed by Klebsiella species at about 24%. 

Conclusion: Despite growing more uropathogens at urine WBCs > 100, only 6% of the patients had a clinically significant UTI. The low prevalence of UTIs in our study of 377 patients is reflective of inappropriate testing and maintaining our urine culture reflex criteria at > 20 WBCs/hpf keeps sensitivity high at above 95% However, specificity is low at 35%. There may be a future role in increasing the threshold for urine reflex to culture to sacrifice some sensitivity for improved specificity and a decrease in unnecessary labor for microbiology labs. 



Email: [email protected]
Moderators
NH
Presenters
avatar for Jason Tuttle

Jason Tuttle

PGY1 Pharmacy Resident, CHI Memorial Hospital
My name is Jason Tuttle, PharmD, and I am a PGY1 resident at CHI Memorial Hospital. I attended pharmacy school at the University of Tennessee Health Science Center College of Pharmacy and was also a pharmacy intern at Blount Memorial Hospital in Maryville, TN. My plans for the future... Read More →
Evaluators
NS
Thursday April 30, 2026 4:40pm - 5:00pm EDT
Athena C
  Internal Medicine (IM), CHI Memorial
  • global Y

4:40pm EDT

Evaluation of Vitamin K Antagonist versus Direct Oral Anticoagulants in the Management of Left Ventricular Thrombus 
Thursday April 30, 2026 4:40pm - 5:00pm EDT
Athena D
 
Authors: Seana-Pierre Williams, Jaleesa Myers 
Wellstar Cobb Medical Center, Austell, GA 
 
Purpose: Left ventricular thrombus (LV thrombus) is a complication arising from left ventricular dysfunction, secondary to acute myocardial infarction or nonischemic cardiomyopathies. The current standard of care for the management of LV thrombus involves anticoagulation with warfarin, a vitamin K antagonist (VKA). While large-scale randomized controlled trials comparing the efficacy of direct oral anticoagulants (DOACs) to VKAs in this context are lacking, several retrospective analyses have demonstrated that DOACs may be non-inferior to VKAs with respect to mortality, incidence of stroke, and thrombus resolution. However, controversy remains regarding the off-label use of DOACs for this indication. The primary objective of this study is to evaluate the safety and efficacy of DOACs in comparison to warfarin in patients diagnosed with LV thrombus, and to assess anticoagulant prescribing patterns in the management of LV thrombus within Wellstar Health System.  
 
Methods: This study was a multicenter, retrospective chart review. Patients admitted to Wellstar Health System with a diagnosis of intracardiac thrombus (ICD-10 codes: I51.3 or I23.6), aged 18 years and older, and received either a DOAC (apixaban, rivaroxaban) or VKA (warfarin) for the management of LV thrombus were eligible for inclusion in this study. Data was collected from electronic medical records between January 1, 2023, and January 1, 2025. The target sample size was 100 patients, with 50 patients in each treatment cohort. Data was collected on the first 100 patients to meet the inclusion criteria within the specified time frame. The primary outcome of this study is the incidence of thromboembolic events, defined as recurrent left ventricular thrombus, stroke, or systemic embolism occurring within 90 days of treatment initiation. Secondary outcomes include left ventricular thrombus resolution within 90 days, hospital length of stay, incidence of bleeding events requiring blood transfusion within 90 days, and 30-day hospital readmission rates. 
 
Results: A total of 100 patients diagnosed with LV thrombus were included in this study. Fifty patients received warfarin and 50 received a DOAC. Of the patients prescribed a DOAC, 5 received rivaroxaban and 45 received apixaban. There was no statistically significant difference in the composite outcome of the incidence of thromboembolic events within 90 days between the warfarin and DOAC groups. There were no statistically significant differences between the warfarin and DOAC groups when comparing the rate of stroke (0% vs. 0%) and systemic embolism (2% vs. 4%). No recurrent LV thrombus within 90 days of treatment initiation were noted in either treatment groups. There were no bleeding events requiring blood transfusions within 90 days. The median length of hospital stay was 10 days (IQR 7–17) in the warfarin group versus 9 days (IQR 4–13) in the DOAC group with no statistically significant difference between groups. Thirty-day hospital readmission rates did not differ significantly between the groups.  
 
Conclusion: Based on the results of this study, DOACs may be as safe and efficacious as warfarin for the management of LV thrombus. This data underscores the importance of further large-scale, randomized controlled clinical trials to inform treatment decisions. Currently, the choice between warfarin and DOACs is informed by limited comparative data. However, both pharmacologic treatment options are used in clinical practice. 
 

Moderators
AM
Presenters
avatar for Seana-Pierre Williams

Seana-Pierre Williams

PGY1 Pharmacy Resident, Wellstar Cobb Medical Center
Hello, my name is Seana-Pierre Williams, and I am currently a PGY1 Pharmacy Resident at Wellstar Cobb Medical Center. My professional interests include critical care, internal medicine, and ambulatory care. I am passionate about addressing healthcare disparities and improving patient... Read More →
Evaluators
avatar for Martin Gordon

Martin Gordon

Clinical Pharmacy Specialist - Critical Care, Spartanburg Medical Center
Martin Gordon, PharmD, BCCCP is the Clinical Pharmacy Specialist for the Medical ICU and Residency Director for the PGY1 Residency Program at Spartanburg Medical Center in Spartanburg, South Carolina.

Martin completed his Doctor of Pharmacy degree from Presbyterian College School of Pharmacy and completed a PGY1 Pharmacy Practice and PGY2 in Critical Care Residency at Spartanburg Medical Center in Spartanburg, SC... Read More →
Thursday April 30, 2026 4:40pm - 5:00pm EDT
Athena D
  Internal Medicine (IM), Wellstar Cobb Medical Center PGY1
  • global Y

4:40pm EDT

Standardizing Biologics Management: A Community Health System Approach to Formulary Development and Implementation
Thursday April 30, 2026 4:40pm - 5:00pm EDT
Olympia 1
Healthcare is undergoing a transformative shift, largely driven by the growing utilization of biologic therapies. While biologics have significantly advanced the treatment of complex and chronic diseases, their high costs have introduced considerable financial strain on both healthcare systems and patients. The creation of biosimilars, agents that are highly similar to their branded reference biologics, have emerged as a promising solution. They offer substantial cost savings and increased patient access without compromising therapeutic efficacy. However, the widespread adoption of biosimilars has been hindered by several challenges, including complex regulatory pathways, evolving reimbursement models, inventory management issues, and payer-imposed restrictions.

Developing and implementing a biosimilar formulary presents unique challenges that Pharmacy and Therapeutics (P&T) Committees have not traditionally encountered. This project was initiated with two primary objectives. The first objective is to establish a systematic process for evaluating both current and future biologic agents in order to develop and maintain a comprehensive formulary for the health system. To achieve this, a structured evaluation framework was created, encompassing key considerations such as drug availability, acquisition cost, site of care, reimbursement pathways, payer policies, and patient access. The data collected through this framework is then analyzed and synthesized into a biologics formulary. Unlike traditional formularies, which often designate a single preferred agent, this biologics formulary ranks the reference product and its biosimilars by site of care, enabling more nuanced and context specific decision making.

The second objective is to implement a standardized workflow that integrates formulary based decision making into clinical practice seamlessly, with no disruption to patient care. To accomplish this, a multidisciplinary team of clinical providers, prior authorization coordinators, and reimbursement specialists collaborates to operationalize the formulary. This integrated approach ensures that the most clinically and economically appropriate agent is selected, balancing the needs of both the health system and the patient.

Looking at biologic invoices for the cancer center with actionable products from September 1, 2025 to March 30, 2026, a total of 963 units were purchased equaling a total of $890,795.56. Reference products accounted for $261,456.22 of the total with only 109 units purchased. Even though the quantity of biosimilars purchased was initially greater than expected, there was a lack of consistency in ordering prior to initiating the formulary, creating missed opportunity for selecting the preferred product with the most reimbursement. Based on the same purchasing data, if all products were switched to the most preferred biologic, it is estimated to have saved a total of $496,625.04. The totals excluded biologics that did not have available biosimilars.

Implementing a biologic formulary has the potential to generate considerable savings and reimbursement. The creation and maintenance of the formulary was without significant challenge. However, the implementation into patient care did have a few setbacks. Most notably there were multiple instances where the most preferred product could not be selected due to insufficient quantities available for purchase, forcing the decision to choose the next best product with reliable stock to not delay patient treatment. There are also instances where patient preference for convenience outweighs the transition to the preferred biosimilar. The majority of implementation of the biosimilar formulary remains at initiation of a new start to therapy, with a few patients transitioning to the preferred biosimilar at the time of insurance authorization renewal. Despite the few setbacks, the initial data are reassuring to confirm the potential of cost savings and maximizing reimbursement to lower financial burden on both the health system and patients.
Moderators
RT
Presenters
avatar for Julia Williamson
Evaluators
KC

Katie Coffee

PGY1 Residency Program Director, Kaiser Permanente Georgia
Thursday April 30, 2026 4:40pm - 5:00pm EDT
Olympia 1
  Internal Medicine (IM), Cookeville Regional Medical Center
  • global Y

5:00pm EDT

Evaluation of Inpatient Opioid Use in Opioid-Naive Patients without an Acute Pain Indication
Thursday April 30, 2026 5:00pm - 5:20pm EDT
Athena J
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. 

Moderators
RF
Presenters
avatar for Taylor Romine

Taylor Romine

PGY1 Pharmacy Resident, Baptist Health Princeton Hospital
Taylor Romine is a PGY-1 pharmacy resident at Baptist Health Princeton Hospital. She earned her Doctor of Pharmacy and Master's in Healthcare Administration from Samford University in Birmingham, AL. She is planning to complete a PGY-2 in internal medicine at Baptist Health Princeton... Read More →
Evaluators
avatar for Rachel Langenderfer

Rachel Langenderfer

Clinical Pharmacy Specialist - Residency Program Coordinator, Bon Secours St. Francis Downtown
I am a clinical pharmacy specialist at Bon Secours St. Francis Downtown Hospital, and I serve as the PGY-1 Residency Program Coordinator and the PGY-2 Internal Medicine Residency Program Director. I went to Campbell University College of Pharmacy and Health Sciences and completed... Read More →
Thursday April 30, 2026 5:00pm - 5:20pm EDT
Athena J
  Internal Medicine (IM), Baptist Health Princeton Hospital
  • global Y

5:00pm EDT

Improving VTE Prophylaxis in Multiple Myeloma: An EHR-Based Approach Using IMPEDE and SAVED Risk Stratification Score in an Outpatient Setting
Thursday April 30, 2026 5:00pm - 5:20pm EDT
Parthenon 2
Improving VTE Prophylaxis in Multiple Myeloma: An EHR-Based Approach Using IMPEDE and SAVED Risk Stratification
Score in an Outpatient Setting
Purpose:
Multiple myeloma patients are at an increased risk of venous thromboembolism due to drug usage, decreased mobility,
and hypercoagulability. Use of IMPEDE/SAVED score to determine prescribing of VTE prophylaxis has resulted in
significantly lower risk of venous thromboembolism. Real world data are needed to determine whether implementation
of a new electronic health record (EHR) system incorporating these scoring tools improves the effectiveness of guiding
thromboembolism prophylactic treatment in multiple myeloma patients, as clinical trial results may not fully reflect their
impact across diverse patient populations, practice settings, and workflow environments.
Methods:
This retrospective, single-center, quality improvement evaluated newly diagnosed patients with multiple myeloma (MM)
before and after implementation of IMPEDE and SAVED risk stratification score that was integrated in an EHR treatment
order set to guide prophylaxis selection. The pre-intervention group was managed using Varian EHR system, whereas the
post-intervention group used Cerner EHR platform, where the order set was implemented. Although the risk scores were
calculated by the treating physicians, integration of the order set serves as a structured reminder to promote consistent
risk assessment and documentation. The primary outcome was guideline adherence to VTE prophylaxis, with secondary
outcomes including incidence of VTE within six months of prophylaxis and assessing risk reclassification.
Results
A total of 19 patients with MM were included with 8 in the pre-intervention group using Varian EHR, and 11 patients in the
post-intervention group following Cerner EHR implementation with VTE prophylaxis order sets. Guideline adherence to
NCCN recommended VTE prophylaxis based on SAVED and IMPEDE scores were 87.5% and 25% pre-intervention versus
63.6% and 36.4% post-intervention, respectively. No patients receiving prophylactic anticoagulation developed VTE
within six months, and one pre-intervention patient (12.5%) had a prophylaxis change after crossover to the post
intervention period.
Conclusion
Implementation of IMPEDED and SAVED VTE risk stratification score being added to treatment order sets demonstrated
variable adherence to guideline recommended prophylaxis but was associated with no observed VTE events among
patients receiving prophylaxis. Larger studies are needed to further evaluate clinical impact and prescribing consistency
Moderators
avatar for Sheema Hallaji

Sheema Hallaji

PGY1 Residency Director, Cone Health- Alamance Regional Medical Center
Presenters
SL
Evaluators
avatar for Savannah Owen

Savannah Owen

Assistant Professor of Pharmacy Practice, South College School of Pharmacy
Savannah Owen earned her PharmD from Auburn University Harrison College of Pharmacy. Since graduating, she has completed the PGY-1 community pharmacy residency at South College School of Pharmacy in Knoxville, TN. She also completed an ambulatory care PGY-2 residency with St. Peter... Read More →
Thursday April 30, 2026 5:00pm - 5:20pm EDT
Parthenon 2
  Internal Medicine (IM), John D. Archbold Memorial Hospital
  • global Y

5:00pm EDT

Lipoglycopeptides Unleashed: The Power of Dalbavancin and Oritavancin
Thursday April 30, 2026 5:00pm - 5:20pm EDT
Athena C
Title: Lipoglycopeptides Unleashed: The Power of Dalbavancin and Oritavancin 

Authors: Michael Wallace, Heather Gibson, Gretchen Arnoczy, Allison Cid  

Background: Lipoglycopeptides are newer antimicrobial agents used to treat gram positive bacterial infections that would otherwise require long term therapy. Advantages include less frequent dosing, no need for pharmacokinetic monitoring, and long half-lives. The long-acting effects of dalbavancin or oritavancin are useful to help prevent patients from needing long-term intravenous access for IV antibiotics and hospital admission. The purpose of this study was to compare the costs between dalbavancin and oritavancin use compared to traditional therapy for gram-positive infections.   
Methods: This was a retrospective, multicenter cohort study at a rural, community health system that included patients who received either dalbavancin or oritavancin at an outpatient infusion center. Patients were included if they received dalbavancin or oritavancin from September 2022 to September 2025. Excluded patients were those that are incarcerated, pregnant women, those younger than 18 years old, or received dalbavancin or oritavancin inpatient. The primary outcome of the study was cost minimization with comparisons between oritavancin and dalbavancin and the standard treatment for gram-positive infections. Secondary outcomes included adverse events, clinical failure, and mortality. Clinical characteristics such as organism, type of infection, and rationale for dalbavancin or oritavancin use were recorded.  

 Results: A total of 110 patients were included in this study, 103 in the dalbavancin group and 7 in the oritavancin group. The total cost savings were stratified based upon indication for both medications. Overall total cost savings for dalbavancin was $308,788.83 and total cost savings for oritavancin was $54,327.54. Total hospital days saved for dalbavancin were 298 and 26 days for oritavancin. The 90-day hospital readmission rate was 20/103 (19%) in the dalbavancin group and 1/7 (14%) in the oritavancin group. The most common organisms in the dalbavancin group were Methicillin-resistant Staphylococcus aureus (MRSA) with 30/104 (29%) and polymicrobial with 31/103 (30%) and in the oritavancin group was unknown organism with 3/7 (43%). Clinical failure rates for dalbavancin were 14/103 (13%) of patients and oritavancin was 2/7 (28%). 90-day mortality rates for the dalbavancin group were 3/103 (3%) and none in the oritavancin group. 

Conclusions: In this study, the clinical utility, cost saving, and decreased length of hospital stays was shown with implementation of dalbavancin and oritavancin. Total cost avoided for both medications during the period was $363,114.37.  These results show that the medications will cut costs and facilitate quicker discharge. Further research to showcase the use of long acting lipoglycopeptides at other institutions could reinforce the cost savings potential on a larger scale.  

Moderators
NH
Presenters
MW
Evaluators
NS
Thursday April 30, 2026 5:00pm - 5:20pm EDT
Athena C
  Internal Medicine (IM), FirstHealth Moore Regional Hospital
  • global Y
 
Friday, May 1
 

8:30am EDT

Hospital acquired anemia in non-surgical patients receiving therapeutic anticoagulation versus venous thromboembolism prophylactic anticoagulation
Friday May 1, 2026 8:30am - 8:50am EDT
Athena H
Purpose:
    Hospital-acquired anemia (HAA) is a common complication of hospitalization and is associated with increased length of stay, healthcare costs, readmissions, and mortality. Although anticoagulation therapy carries a known bleeding risk, its role as an independent contributor to HAA has not been well defined. This study evaluated compared the incidence of HAA in non-surgical hospitalized patients receiving prophylactic versus therapeutic anticoagulation.
Methods:
    This retrospective cohort study included adults (≥18 years) hospitalized for more than 4 days who received prophylactic or therapeutic anticoagulation for over 75% of their admission. Prophylactic regimens included subcutaneous heparin, prophylactic-dose enoxaparin, or fondaparinux 2.5 mg daily. Therapeutic anticoagulation included direct oral anticoagulants, intravenous heparin, therapeutic-dose enoxaparin, argatroban, or fondaparinux ≥ 5 mg daily. Patients were required to have hemoglobin measured on admission and within 72 hours of discharge. Exclusion criteria included anemia on admission, surgical procedures (excluding minor/low-risk procedures), therapies affecting hemoglobin, or documented physiologic bleeding.
Results:
    Hospital-acquired anemia occurred in 44.8% of patients receiving prophylactic anticoagulation and 51.3% receiving therapeutic anticoagulation, with no significant difference between groups (p = 0.28). No differences were observed in anemia severity, absolute hemoglobin change (p = 0.93), or rate of hemoglobin decline (p = 0.74).
Conclusion:
    Hospital-acquired anemia was common in non-surgical hospitalized patients, with no significant differences between prophylactic and therapeutic anticoagulation. Anticoagulation intensity alone may not be a primary contributor to HAA.
Moderators
AC
Presenters
avatar for Kaitlyn Kuntz

Kaitlyn Kuntz

PGY-1 Resident, University of Tennessee Medical Center
Evaluators
avatar for Anh Nguyen

Anh Nguyen

Clinical Pharmacy Specialist, Emory Decatur Hospital
I’m a Board‑Certified Critical Care Pharmacy Specialist with a passion for taking care of some of the sickest patients in the hospital. I’ve worked in both intermediate and intensive care settings, where every day brings a new challenge and a new opportunity to make a meaningful... Read More →
Friday May 1, 2026 8:30am - 8:50am EDT
Athena H
  Internal Medicine (IM), University of Tennessee Medical Center
  • global Y

8:30am EDT

Hydrocortisone vs. Methylprednisolone for the Treatment of Refractory Septic Shock
Friday May 1, 2026 8:30am - 8:50am EDT
Athena B
Title: Hydrocortisone vs. Methylprednisolone for the Treatment of Refractory Septic Shock 
Authors: Erin Weippert, Sydney Kisala, Van Bui, Sarah Jung, Marina Rabinovich  
Background: The 2024 Society of Critical Care Medicine Guidelines on the Use of Corticosteroids in Sepsis recommend the use of corticosteroids in patients with septic shock. The recommended regimen is hydrocortisone 200 – 300 mg intravenously (IV) per day in divided doses or as a continuous infusion. Due to an ongoing IV hydrocortisone shortage, IV methylprednisolone is increasingly used as an alternative, though evidence for its safety and efficacy in septic shock is limited. The purpose of this study was to compare the effectiveness and safety of methylprednisolone to hydrocortisone in the management of refractory septic shock. 
Methods: This was a single-center, retrospective, cohort study conducted at a safety net hospital in Atlanta, GA. Patients with septic shock who received methylprednisolone during the primary and secondary IV hydrocortisone shortage periods (February 2023 - February 2024 and May - August 2025) were compared with patients who received hydrocortisone (February 2024 - February 2025). Eligible patients were at least 18 years old, admitted to an intensive care unit (ICU), diagnosed with septic shock requiring at least two vasopressors, and received at least 48 hours of either IV methylprednisolone or IV hydrocortisone. Patients were excluded if they were pregnant, received corticosteroids for an alternative indication, or received both hydrocortisone and methylprednisolone. Variables collected include patient demographics, highest serum lactate level, initial Sequential Organ Failure Assessment (SOFA) score, type and number of vasopressors received, source of infection, steroid duration, and time from shock onset to steroid initiation. The primary outcome was time to shock resolution, defined as the attainment of a goal mean arterial pressure (MAP) ≥ 65 mmHg without vasopressor support for at least 24 hours. Secondary outcomes included the incidence of shock recurrence, time to achieving lactate of < 2 mmol/L, receipt of vasopressors and corticosteroids beyond 7 days, hospital mortality at 28 days, ICU length of stay, and duration of corticosteroid therapy. Safety outcomes included the incidence of hyperglycemia, hypernatremia, and gastrointestinal bleeding. Descriptive statistics were used for analysis and categorical variables were compared using a chi-square or Fisher’s exact test while continuous variables were compared using the Mann-Whitney U test. A p-value of 0.05 was considered statistically significant. 
Results: A total of 191 patients were included for analysis with 116 included in the hydrocortisone group and 75 in the methylprednisolone group. Baseline characteristics were similar between groups with the majority of patients being male, of Black or African American race, median age of 60 years, and admitted to the medical ICU. However, patients in the methylprednisolone group had a greater need for renal replacement therapy (50.6% vs. 35.3%, p=0.036). 85 patients (73.3%) in the hydrocortisone group and 50 patients (67%) in the methylprednisolone group achieved shock resolution (p=0.327). The primary outcome of time to shock resolution was similar in the two groups (4 days vs. 3.9 days, p=0.479). For secondary outcomes, there were no significant differences between the groups for recurrence of shock, time to achieving lactate of < 2 mmol/L, or ICU length of stay. More patients in the hydrocortisone group received vasopressors and corticosteroids beyond seven days (25.9% vs. 9.3%, p=0.005), while the methylprednisolone group exhibited a higher 28-day hospital mortality (56% vs. 38.8%, p=0.02). There were no significant differences in safety outcomes between the groups. 
Conclusions: The results of this study demonstrated no difference in time to shock resolution between hydrocortisone and methylprednisolone in critically ill patients with septic shock. These results suggest that methylprednisolone may be a reasonable alternative to hydrocortisone in this patient population, although larger prospective studies are needed to confirm these findings and evaluate long-term outcomes.  

Moderators
avatar for Abigayle Campbell

Abigayle Campbell

Clinical Specialist, Psychiatry; PGY1 Acute Care RPC, Self Regional Healthcare
For the past 6 years, I have served as the Clinical Pharmacy Specialist within the Inpatient Behavior Health Center at Self Regional Healthcare in Greenwood, SC. Recently, I have transitioned into a new role as the Medication Utilization and Quality Coordinator. I completed my bachelor's... Read More →
Presenters
avatar for Erin Weippert

Erin Weippert

PGY-1 Pharmacy Resident, Grady Memorial Hospital
Evaluators
ST
Friday May 1, 2026 8:30am - 8:50am EDT
Athena B
  Internal Medicine (IM), Grady Memorial Hospital
  • global Y

8:30am EDT

Incidence of Ribociclib-Induced Serum Creatinine Elevation in Hormone Receptor-Positive Breast Cancer
Friday May 1, 2026 8:30am - 8:50am EDT
Athena C
Background: Ribociclib is a cyclin-dependent kinase 4 and 6 inhibitor approved for treatment of   advanced or metastatic hormone receptor (HR) positive, human epidermal growth factor receptor 2 (HER2) negative breast cancer at a dose of 600 mg and adjuvantly for high-risk, early-stage HR+, HER2- breast cancer at a dose of 400 mg . While ribociclib has resulted in improved cancer-related outcomes, the incidence of ribociclib-induced serum creatinine (SCr) elevations has been reported in 8-65% of patients in phase 3 trials although up to 73% of those cases are attributed to a phenomenon known as pseudo-acute kidney injury (AKI). The proposed mechanism is thought to be due to ribociclib’s competitive inhibition of renal tubular secretion transporters, OCT2, MATE1, MATE2-K, blocking creatinine secretion into urine without affecting actual glomerular filtration rate. Cystatin C is an alternative surrogate marker of renal function that is not affected by ribociclib’s inhibition of renal tubular transporters and thus may be utilized to distinguish pseudo-AKI from true kidney injury. This study aimed to further describe the nature and clinical significance of ribociclib-induced SCr elevation in patients with HR+, HER2- breast cancer in a real-world setting.  

Methods: This IRB approved, single-center, retrospective chart review included all adult patients prescribed ribociclib for HR+, HER2- breast cancer at Emory Winship Cancer Institute between October 2022 and August 2025. Patients were excluded if ribociclib was prescribed by an external provider, used for investigational purposes, or if baseline SCr documentation at least 6 months prior to ribociclib initiation was missing. The primary outcome was incidence of ribociclib-induced SCr elevation, defined as ≥ grade 1 per CTCAE v5.0. Cystatin C, defined as > 0.95 mg/dL, was utilized to assess reduced renal function. Use of concomitant nephrotoxic medications including CT contrast, zoledronic acid, diuretics, NSAIDs, metformin, antihypertensives, and antibiotics was assessed.  

Results: 168 females and 2 males were reviewed, median age 58 years old. The majority (139 patients, 81.7%), were prescribed ribociclib for metastatic disease; 31 (18.2%) adjuvantly. Ribociclib-induced SCr elevation occurred in 49 patients (28.8%). Of those patients, 40 (81.6%) had metastatic disease, the initial dose was 600 mg for 36 (73.5%), and 47 (95.9%) were prescribed concomitant nephrotoxic medications though not statistically significant (p-value, 0.515). Median absolute change in SCr from baseline was 0.45 mg/dL (range, 0.34-0.54 mg/dL); median time to SCr elevation was 33 days (range, 15-83 days). Most events were grade 2 (35, 71.4%); 14 (28.6%) were grade 1. Of those with elevated SCr, 5 patients (10.2%) had true kidney injury as indicated by an elevated cystatin C warranting consideration of dose interruption or reduction. Median time to SCr recovery was 155 days (range, 27-316 days).

Conclusion: Ribociclib-induced SCr elevation often occurred within the first or second cycle and remained elevated yet stable through the first six cycles. The majority were grade 1 or 2 events and did not require dose reductions or interruptions.
Moderators
DK
Presenters
avatar for Madeline Adams

Madeline Adams

PGY1 Acute Care Pharmacy Resident, Emory University Hospital Midtown
Evaluators
avatar for Allie Hale

Allie Hale

Clinical Pharmacist and Residency Program Director, Parkridge Health System
Friday May 1, 2026 8:30am - 8:50am EDT
Athena C
  Internal Medicine (IM), Emory University Hospital Midtown
  • global Y

8:50am EDT

Impact of a Pharmacist-Led COPD Transitions of Care Program on 30-Day Readmission Rates
Friday May 1, 2026 8:50am - 9:10am EDT
Olympia 2
Title: Impact of a Pharmacist-Led COPD Transitions of Care Program on 30-Day Readmission Rates

Authors: Allison Edmondson, Quyen Nguyen, Jeremy Walley

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality in the United States. The total annual medical costs for COPD near 24 billion dollars, with the cost of inpatient care accounting for 6.3 billion of those dollars. Additionally, COPD is a target condition under the Centers for Medicare and Medicaid Services under the Hospital Readmissions Reduction Program. COPD readmissions pose a significant economic burden to the healthcare system and may result from gaps in care during transitions from the hospital back to home. Transitions of care interventions by pharmacists can assist in bridging gaps in care for these patients.

Methods: This study will implement a pharmacist-led transitions of care program for patients admitted to the hospital with a COPD exacerbation. Pharmacists will assist in optimizing COPD regimens, medication and inhaler technique counseling, medication access, education on symptom self-management, and post-discharge follow-up phone calls. The primary objective is to evaluate the impact of the transitions of care service on 30-day readmission rates for COPD exacerbation within the facility. Secondary objectives will include pharmacist interventions performed.

Results: A total of 102 patients were included in the study. Readmission rates among COPD patients prior to the transition of care service in December 2024 to March 2025 were 27%, compared with 17% following the implementation of the service between December 2025 to March 2026. The primary pharmacist interventions performed included recommendations to change inhaler therapy, phone call follow up, and patient education. Among patient home medications, there was a 20.7% increase of patients on guideline-directed COPD therapy from admission to discharge.

Conclusions: The implementation of a pharmacist-led COPD transitions of care service appeared to decrease 30-day readmission rates. Pharmacists can play a role in helping to optimize therapy, medication access, patient education, and enhancing follow-up care.
Moderators
avatar for Brian Leith

Brian Leith

Clinical Pharmacist, VA Medical Center
I am currently the emergency medicine and antimicrobial stewardship pharmacist at the VA Medical Center in Fayetteville, NC.
Presenters
avatar for Allison Edmondson
Evaluators
BK

Brian Knott

Clinical Pharmacy Manager, AdventHealth Winter Park
Friday May 1, 2026 8:50am - 9:10am EDT
Olympia 2
  Internal Medicine (IM), Cookeville Regional Medical Center
  • global Y

8:50am EDT

Impact of a Practice Advisory Alert on the Duration of Antibiotics Prescribed at Discharge
Friday May 1, 2026 8:50am - 9:10am EDT
Parthenon 2
Authors: Savannah Odom, Lauren Freeman, Hannah Harpe
Objective: This study evaluates the effectiveness of a practice advisory alert in improving antibiotic prescribing at hospital discharge.
Background: Antimicrobial resistance is a major and growing global public health threat, driven largely by antimicrobial misuse and overuse. Inappropriate antibiotic prescribing at hospital discharge is a key contributor, with studies demonstrating that durations frequently exceed guideline recommendations. Prior research has shown that antibiotic overuse occurs in up to 75% of patients, primarily due to excessive treatment duration and failure to account for inpatient therapy. This highlights a critical opportunity for antimicrobial stewardship interventions targeting transitions of care to optimize antibiotic use and improve patient outcomes. Building on a prior institutional initiative in which a fluoroquinolone-specific alert significantly reduced treatment duration, this study assesses whether expanding the alert to additional antibiotic agents results in similar improvements in prescribing practices. The alert prompts providers to account for inpatient antibiotic days when determining discharge durations, supporting appropriate therapy length and antimicrobial stewardship efforts.
Self Assessment Question: What was the main finding after implementation of the practice advisory?
Methods: This retrospective, multi-center, quasi-experimental study evaluates adults discharged on oral antibiotics before (January 2025-February 2025) and after (January 2026-February 2026) implementation of a practice advisory. A random sample from the pre-intervention group is matched 1:1 to the post-intervention group by antibiotic and indication. Patients receiving antibiotics for prophylaxis or suppression, those immunocompromised, or those with severe or complicated infections were excluded. Data collected include demographics, antibiotic regimen and indication, infectious diseases consultation, and prescriber credentials. The primary outcome is the proportion of patients discharged with antibiotic durations consistent with guidelines or infectious diseases recommendations, adjusted for inpatient days of therapy. Secondary outcomes include 30-day treatment for Clostridioides difficile and 30-day all-cause readmission. 
Results: A total of 300 patients were included, with 150 patients in both the pre- and post-intervention groups. Baseline characteristics, including age, sex, infection type, and antibiotic selection, were well balanced between groups. Implementation of the practice advisory alert was associated with a significant improvement in guideline-concordant antibiotic prescribing at discharge, increasing from 53.3% in the pre-intervention group to 81.3% in the post-intervention group (p < 0.001). Thirty-day all-cause readmission rates were 13.3% in the pre-intervention group versus 12% in the post-intervention group (p = 0.73). Additionally, no patients in either group required treatment for Clostridioides difficile infection within 30 days of discharge.
Conclusion: Implementation of an electronic practice advisory alert that incorporates inpatient antibiotic days resulted in a clinically meaningful and statistically significant improvement in appropriate antibiotic duration at discharge. Expansion of this alert beyond fluoroquinolones to a broader range of antimicrobial agents successfully optimized prescribing practices. Importantly, these improvements were achieved without negatively impacting patient safety outcomes, as evidenced by unchanged readmission rates and absence of Clostridioides difficile infection events. Overall, this study demonstrates that targeted electronic clinical decision support tools are an effective and scalable antimicrobial stewardship strategy
Moderators
CM
Presenters
avatar for Savannah Odom

Savannah Odom

PGY-1 Pharmacy Resident, McLeod Regional Medical Center
Evaluators
CT

Christina Thurber

PGY-1 Residency Program Coordinator
Friday May 1, 2026 8:50am - 9:10am EDT
Parthenon 2
  Internal Medicine (IM), McLeod Regional Medical Center
  • global Y

8:50am EDT

Resident Presentation Abstract - Jessica Arnold
Friday May 1, 2026 8:50am - 9:10am EDT
Athena D
The purpose of this study was to evaluate the effect of a pharmacist-led transitions of care (TOC) consult service, specifically designed to address medication access barriers, on patients undergoing inpatient percutaneous coronary interventions. The study sought to assess the program’s impact on medication adherence and hospital readmission rates at 30- and 90-days post-discharge, while also contextualizing these outcomes within the existing body of literature. This retrospective study evaluated the impact of pharmacist-led interventions during TOC consults on medication adherence and hospital readmission. The study period extended from April 1, 2023, through April 1, 2025, providing a two-year window to ensure adequate patient capture. Data were extracted from the electronic health record and entered into REDCap, with all protected health information excluded to maintain confidentiality and compliance with institutional review standards. The primary outcome was the first-fill rate of antiplatelet medications among patients admitted under the post–coronary artery stent pathway who underwent percutaneous coronary intervention during their inpatient stay at this academic medical center, assessing whether pharmacist engagement improved timely medication initiation in a population at elevated cardiovascular risk. Secondary outcomes included 30-day and 90-day readmission rates, documentation of pharmacist clinical interventions across inpatient and outpatient settings, and the type of medication access support provided to patients who filled their antiplatelet prescriptions at the hospital’s affiliated outpatient pharmacy at discharge, providing additional insight into the broader impact of pharmacist involvement during care transitions. The primary endpoint was analyzed using a chi-square test, and descriptive and inferential statistics were applied to secondary outcomes as appropriate. Collectively, this study aimed to characterize the role of pharmacists in optimizing medication use, reducing readmissions, and improving outcomes for patients undergoing percutaneous coronary intervention.
Moderators
avatar for Christele Robinson

Christele Robinson

Emergency Medicine Clinical Pharmacy Specialist, Emory University Hospital
Christele Robinson, PharmD, is board certified in pharmacotherapy. She is a member of the Department of Pharmacy at Emory University Hospital and currently practicing as an Emergency Medicine Clinical Pharmacy Specialist. Dr. Robinson obtained a Bachelor of Science degree at the... Read More →
Presenters
avatar for Jessica Arnold

Jessica Arnold

PGY1 Pharmacy Resident, University of Tennessee Medical Center
Evaluators
avatar for Cody Parker

Cody Parker

Clinical Pharmacy Specialist, St. Joseph's/Candler
Dr. Cody Parker is the PGY1 Pharmacy Residency Program Director at St. Joseph's/Candler in Savannah, GA. He received his Doctor of Pharmacy from the University of Georgia and completed a Postgraduate Year One (PGY1) Pharmacy Practice Residency at St. Joseph’s/Candler. Dr. Parker is a Clinical Pharmacy Sp... Read More →
Friday May 1, 2026 8:50am - 9:10am EDT
Athena D
  Internal Medicine (IM), University of Tennessee Medical Center
  • global Y

9:10am EDT

Appropriate Diagnosis of Sepsis via SIRS Criteria and Opportunities for Reduction in Broad-Spectrum Antibiotic Use in the Emergency Department
Friday May 1, 2026 9:10am - 9:30am EDT
Olympia 2
Purpose: Time-sensitive completion of bundled interventions is the focus of the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Centers for Medicaid and Medicare Services (CMS) quality measure, which aims to reduce sepsis-related morbidity and mortality. To avoid missed cases of sepsis, clinicians often rely on the Systemic Inflammatory Response Syndrome (SIRS) criteria as the major identifier of sepsis, which has inadvertently raised concerns for potential overdiagnoses. This study evaluated the incidence of patients diagnosed with sepsis in the emergency department (ED) who did not meet SIRS criteria and/or lacked a documented source of infection. Recognizing such cases may highlight opportunities to reduce unnecessary use of broad-spectrum antibiotics and ultimately support more targeted antimicrobial stewardship in sepsis care.
Methods: This study design was submitted to the Ballad Health System Institutional Review Board for approval. This was a retrospective electronic chart review that included adult patients aged 18 years and older who presented to the ED of Bristol Regional Medical Center, Holston Valley Medical Center, or Johnson City Medical Center between December 2025 and March 2026 with a sepsis ICD-10 diagnosis. Using the electronic health record, we identified patients who were reported to have met the SIRS criteria. Among these qualifying candidates, patients were then assessed whether there was a documented source of infection and whether broad-spectrum antibiotics were administered. Data collected included patient age, gender, ethnicity, respiratory rate, heart rate, temperature, white blood cell count, and antibiotics received. Provider documentation was reviewed to verify whether there was a documented source of infection. All data was reviewed and recorded in a manner that ensured complete patient anonymity. Statistical analysis was conducted to compare groups meeting sepsis criteria, antibiotic use, and documented infection source.
Results: Among evaluated patients, 11% of those diagnosed with sepsis in the ED did not meet greater than two SIRS criteria at initial presentation, while 89% met SIRS criteria. Additionally, 3% of the study population lacked a documented or suspected source of infection. Clinician compliance with SIRS-based sepsis diagnosis across facilities ranged from 81% to 97%, exceeding the pre-study hypothesis of 70%. Cefepime and vancomycin were the most commonly utilized antimicrobials, with broad-spectrum antibiotic use occurring in approximately 90% of patients.
Conclusions: Majority of patients diagnosed with sepsis in the ED met SIRS criteria, with compliance rates higher than initially anticipated. However, a subset of patients did not meet diagnostic criteria or lacked an identifiable infectious source, suggesting potential opportunities for improvement with diagnostic accuracy and reducing unnecessary broad-spectrum antibiotic use. Further studies with larger sample sizes and less exclusion criteria are warranted to better assess antimicrobial appropriateness based on patient-specific risk factors and presumed sources of infection.
Moderators
avatar for Brian Leith

Brian Leith

Clinical Pharmacist, VA Medical Center
I am currently the emergency medicine and antimicrobial stewardship pharmacist at the VA Medical Center in Fayetteville, NC.
Presenters
avatar for AnaLeigh Cook

AnaLeigh Cook

PGY1 Pharmacy Resident, Bristol Regional Medical Center


Evaluators
BK

Brian Knott

Clinical Pharmacy Manager, AdventHealth Winter Park
Friday May 1, 2026 9:10am - 9:30am EDT
Olympia 2
  Internal Medicine (IM)
  • global Y

9:10am EDT

Comparing Safety and Efficacy of Subcutaneous Unfractionated Heparin Dosing Frequencies for Venous Thromboembolism Prophylaxis in a Community Hospital
Friday May 1, 2026 9:10am - 9:30am EDT
Parthenon 1
Comparing Safety and Efficacy of Subcutaneous Unfractionated Heparin Dosing Frequencies for Venous Thromboembolism Prophylaxis in a Community Hospital
Authors: Jonathan Johnson, Adam Harnden, Madison Sanders, M. Trey Dailey, Nancy Bailey, Matthew Hadley
Background: Venous thromboembolism (VTE) is a major cause of in-hospital morbidity and mortality with an estimated 375,000 new cases and approximately 100,000 deaths annually in the United States. Patients in the hospital are at a higher risk of developing VTE due to underlying conditions and acute illness. Using unfractionated heparin (UFH) to prevent VTE is an appropriate choice of therapy to decrease the risk of VTE events and death; however, there is not a consensus on administration frequencies. This study aimed to assess the safety and efficacy between dosing strategies in patients that were admitted to a community hospital.
Methods: This retrospective, institutional review board approved study, was conducted at a 344-bed community hospital in Montgomery, Alabama. A clinical decision support tool was utilized to identify patients receiving UFH 5,000 units subcutaneously twice daily (BID) or three times daily (TID) between January 1, 2024 to December 31, 2024. Patients included in the study were at least 19 years old, non-surgical, and received prophylactic UFH 5,000 units for at least 48 hours dosed either BID or TID. Patient populations excluded were pregnant patients, trauma patients, those on continuous renal replacement therapy, those who had a major bleed upon admission, therapeutic anticoagulation doses for more than 12 hours, received low molecular weight heparin or fondaparinux, or if patients received both UFH dosing schedules for at least 48 hours. Patients were separated into two cohorts of UFH dosing: BID or TID. The primary endpoint of this study was the incidence of VTE events. Secondary endpoints included incidence of the individual components of VTE: deep vein thrombosis and pulmonary embolism. Other secondary endpoints included major and minor bleeding, heparin-induced thrombocytopenia, hospital length of stay (LOS), hospital re-admission, and in-hospital mortality. Data for the study were collected from an on-site secure electronic medical record where patient information was reviewed. Power was calculated through an open-access statistical analysis software such that 120 patients were required to reach 90% power. Appropriate statistical tests were applied to analyze data as well as appropriate use of descriptive statistics.
Results: A total of 140 patients were included in this study with 70 patients in each arm, meeting protocol. A total of 156 patients were excluded with the majority due to not receiving doses for at least 48 hours.  The primary outcome, incidence of VTE, occurred in 1/70 (1%) patients in the TID dosing group compared to no incidence of VTE in the BID group (P=1). The incidence of VTE that occurred in the TID group was due to a deep vein thrombosis. Major bleeding occurred in 1/70 (1%) patients in the TID group and minor bleeding occurred in 1/70 patients (1%) of both the BID and TID groups. Re-admission rates occurred in 35 patients in the BID group compared to 23 patients in the TID group (P=0.06). Incidence of in-hospital mortality occurred in 3 patients in the BID group compared to 10 patients in the TID group (P=0.08). Mean number of days for LOS was 7.94 for the BID group and 10.57 for the TID group (P=0.13).
Conclusion: In this study, patients receiving UFH 5,000 units for VTE prophylaxis had similar safety and efficacy endpoints when comparing BID and TID dosing. Limitations of this study include being a single center study that relied on medical record documentation and having difficulty in extrapolating the results due to the prevalence of hospital acquired VTE.
Moderators
avatar for Devin Lavender

Devin Lavender

Clinical Assistant Professor, UGAA1University of Georgia College of Pharmacy (Ambulatory Care)PGY2
Ambulatory Care, Scholarship of Teaching and Learning, Resident and Student Development.
Presenters
avatar for Jonathan Johnson

Jonathan Johnson

PGY1 Pharmacy Resident, Jackson Hospital and Clinic
For my undergraduate, I graduated from The Citadel, the Military College of South Carolina for biology, and I graduated from the Medical University of South Carolina (MUSC) for pharmacy school. I am a current PGY1 Pharmacy Resident with Jackson Hospital and Clinic in Montgomery, Alabama... Read More →
Evaluators
DT
Friday May 1, 2026 9:10am - 9:30am EDT
Parthenon 1
  Internal Medicine (IM), Jackson Hospital and Clinic

9:10am EDT

Evaluating the implementation of prolonged beta-lactam infusions for sepsis patients in the ICU
Friday May 1, 2026 9:10am - 9:30am EDT
Athena H
Title: Evaluating the implementation of prolonged beta-lactam infusions for sepsis patients in the ICU
Authors: Nathaniel Park, Jeremy Frens, Alex Chappell, and Dustin Zeigler
Background/Purpose:
Beta-lactams are generally the preferred and most frequently prescribed antibiotics to treat patients with sepsis due to their broad spectrum of activity and favorable safety profile. Their efficacy is dependent on time above minimum inhibitory concentration (MIC) with requirements depending on beta-lactam class. Therefore, patients are at risk of treatment failure if beta-lactam concentrations at the site(s) of infection fall below the MIC for extended periods of time. Recently, data from the BLING-III trial and subsequent meta-analyses have suggested that there may be benefits in terms of clinical cure and reduced 90-day mortality with prolonged beta-lactam infusions in comparison with conventional, intermittent infusions. As a result, Cone Health adopted prolonged or continuous infusion protocols for piperacillin/tazobactam, penicillin G, and nafcillin. More recently, additional prolonged infusion protocols were implemented for cefepime, ceftazidime, and meropenem in critically ill patients with sepsis or septic shock. The aim of this study was to evaluate the efficacy and safety associated with the implementation of a prolonged infusion regimen protocol for cefepime, ceftazidime, and meropenem in ICU patients with sepsis or septic shock.
Methodology:
This Institutional Review Board (IRB) reviewed, determined exempt, retrospective, multicenter, single-health system, pre-post study was conducted from October 2024 to December 2025. Patients were included if they were > 18 years old; ICU admission for sepsis or septic shock; had documented site of infection or strong suspicion for bacterial infection; initiated on meropenem, cefepime, or ceftazidime < 24 hours from sepsis or septic shock diagnosis; and > 1 sign of organ dysfunction [mean arterial pressure (MAP) < 60 mm Hg for > 1 hour, vasopressor required > 4 hours, respiratory support required for > 1 hour, or serum creatinine > 2.49 mg/dL]. Exclusion criteria included renal replacement requirement at the time of antibiotic initiation, received antibiotics < 48 hours, and antibiotics not initiated within 24 hours of sepsis diagnosis. Baseline demographic data, safety data, and data relevant to the primary and secondary endpoints were collected among eligible patients. The primary endpoint was ICU length-of-stay (LOS) defined as days on ICU unit. Secondary endpoints were clinical cure (defined as completion of antibiotics within 14 days without resumption within 48 hours of cessation), vasopressor-free days, and 30-day all-cause mortality. Continuous data was analyzed with Student’s t-test or Mann-Whitney U test, and categorical data was analyzed with chi-square test or Fisher’s exact test. Two-sided alpha was set at 0.05.
Results:
In total, 200 patients were screened for inclusion (100 in pre- and 100 in post-intervention cohort). Ultimately, 38 patients were analyzed – 18 in the pre-intervention cohort, and 20 in the post-intervention cohort. Less than half of the patients were female (n=17, 44.7%) with an average age of 71 years old. Most patients were started on cefepime (n=29, 76.3%), with pulmonary and urinary sources accounting for most of the suspected sepsis sources (n=28, 73.7%). Of the 20 patients in the post-intervention cohort, 14 patients met criteria for prolonged beta-lactam infusion. Among patients meeting criteria (n=14), 1 patient (7.1%) received prolonged beta-lactam infusion. For the primary endpoint, the post-intervention group had a shorter median ICU LOS (2.7 vs 5.0 days, p=0.285). For secondary endpoints, the post-intervention group had less vasopressor-free days (0.7 vs 1.1 days, p=0.055), reduced 30-day mortality (15.0% vs 33.3%), and increased clinical cure (90.0% vs 77.8%). One occurrence of a new C. difficile infection occurred, which was in the pre-intervention cohort, and beta-lactams were appropriately renally adjusted in the 27 patients meeting criteria for renal dosing.
Conclusions:
Although numeric differences were observed in favor of the prolonged beta-lactam infusion protocol cohort with decreased ICU LOS, increased vasopressor-free days, 30-day mortality, and clinical cure, there were no statistical differences among any of the primary or secondary endpoints. Additionally, the observed low implementation rate of prolonged beta-lactam infusion among eligible patients further complicates interpretation. Most likely, the cohort identification methods did not have the sensitivity to identify more patients administered prolonged beta-lactam infusions. The results of this study should not dissuade use of the prolonged beta-lactam infusion protocol.
Moderators
AC
Presenters
NP
Evaluators
avatar for Anh Nguyen

Anh Nguyen

Clinical Pharmacy Specialist, Emory Decatur Hospital
I’m a Board‑Certified Critical Care Pharmacy Specialist with a passion for taking care of some of the sickest patients in the hospital. I’ve worked in both intermediate and intensive care settings, where every day brings a new challenge and a new opportunity to make a meaningful... Read More →
Friday May 1, 2026 9:10am - 9:30am EDT
Athena H
  Internal Medicine (IM), Cone Health
  • global Y

9:10am EDT

Evaluation of Febrile Neutropenia Prophylaxis Use in Inpatient Oncology
Friday May 1, 2026 9:10am - 9:30am EDT
Athena G
Evaluation of Febrile Neutropenia Prophylaxis Use in Inpatient Oncology
Olivia Jones, PharmD; Sarah Bowman, PharmD, BCOP; Samantha Lightle, PharmD
Huntsville Hospital – Huntsville, AL


Background: Febrile neutropenia is a common and potentially serious complication among patients with hematologic malignancies. The National Comprehensive Cancer Network (NCCN) provides evidence-based guidance to identify oncology patients who qualify for prophylactic antimicrobial therapy to prevent febrile neutropenia. Consistent application of these recommendations is critical for reducing infection-related morbidity and mortality. Prior evaluation at our institution has highlighted gaps in guideline adherence, particularly among high-risk populations such as patients with acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), myelodysplastic syndromes (MDS), and multiple myeloma (MM). The purpose of this retrospective chart review is to evaluate current antimicrobial prescribing patterns and associated outcomes in these populations.


Methodology: This single-center, IRB-approved, pre–post implementation study was conducted at Huntsville Hospital to evaluate prescribing patterns of prophylactic antimicrobials and associated outcomes in patients at high risk for febrile neutropenia. The pre-intervention group included hospitalized patients with the aforementioned hematologic malignancies between January 1, 2025 and August 31, 2025. Data extracted from the electronic medical record included demographics, chemotherapy regimens, risk factors, use of prophylactic antimicrobial agents, and incidence of febrile neutropenia. Following analysis of baseline data, a disease specific decision support tool and educational initiative were developed and delivered to oncology nurse practitioners and pharmacists in early March 2026. Post-intervention data was collected from the same patient population following March 10, 2026.  The primary outcome was percentage of eligible patients who received appropriate prophylactic antimicrobials.


Results: A total of 87 patients were included in the pre-implementation group and 15 patients in the post-implementation group. Appropriate prophylactic antimicrobial use among eligible patients increased from 42.8% (3/7) to 100% (3/3) for antibacterial prophylaxis and from 50% (10/20) to 100% (3/3) for antifungal prophylaxis. Antiviral prophylaxis increased from 50.9% (26/51) to 57.1% (8/14). Median time to prophylaxis initiation decreased from 80.7 to 4.7 hours for antibacterial agents and from 17.9 to 4.7 hours for antifungal agents. Antiviral prophylaxis showed minimal change in time to initiation (19.6 vs 18.6 hours). Febrile neutropenia incidence did not differ consistently between groups. In the pre-implementation cohort, patients who received prophylaxis had lower absolute neutrophil counts and longer hospital lengths of stay compared to those who did not receive prophylaxis.


Conclusions: A pharmacist-driven educational initiative was associated with improved adherence to guideline-recommended prophylactic antimicrobial use, particularly for antibacterial and antifungal agents, and significantly reduced time to initiation. Variability in antiviral prescribing practices may explain the more modest changes observed in this group. These findings highlight the impact of pharmacist involvement and support further efforts to standardize prophylaxis use earlier in hospitalization.
Moderators
CW

Cassandra Wade

Pharmacy Procurement Coordinator, John D Archbold Memorial Hospital
Presenters
avatar for Olivia Jones

Olivia Jones

PGY-1 Resident, Huntsville Hospital
Evaluators
avatar for Madison Yates

Madison Yates

Clinical Pharmacist Practitioner, PGY1 Ambulatory Residency Program Coordinator, Cone Health
Friday May 1, 2026 9:10am - 9:30am EDT
Athena G
  Internal Medicine (IM), Huntsville Hospital

9:10am EDT

Evaluation of Glucagon-like Peptide-1 Receptor Agonist Use and the Risk of Pancreatitis
Friday May 1, 2026 9:10am - 9:30am EDT
Athena A
Authors: Isaac Sauvageau, Kerri Smith, Brittney Bright, Ryan Imel, Blake Sloan 

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a therapeutic class that mimics the naturally occurring incretin hormone GLP-1. Through this mechanism, they enhance glucose-dependent insulin secretion, suppress glucagon release, delay gastric emptying, and promote satiety. These effects make GLP-1 RAs effective agents for the management of type 2 diabetes mellitus (T2DM) and chronic weight management. They have also demonstrated cardiovascular and renal protective benefits, leading to increased use in patients with cardio-renal comorbidities. Despite their broad acceptance in clinical practice, early clinical trials and observational studies suggest a potential increase in the risk of pancreatitis (0.4% versus 0.03% in the general population). Multiple studies identify an increased risk of pancreatitis across the class, though results remain inconsistent, and the underlying mechanisms are not fully established. 

Methods: This was a multi-center, matched case-control design that included adult patients with active GLP-1 RAs on their home medication lists from May 1, 2024 – October 1, 2025. The primary objective was to determine the incidence of pancreatitis in patients using GLP-1 RAs at North Carolina Baptist Hospital, Highpoint Medical Center, and Davie Medical Center. The secondary objective was to identify patient-specific factors associated with pancreatitis risk among GLP-1 RA users. Patients were excluded from the study if they initiated GLP-1 RA therapy within 30 days of data collection. The incidence of pancreatitis was calculated from the unadjusted population prior to case matching. Cases were defined as GLP-1 RA users admitted to the hospital with a primary diagnosis of pancreatitis. Controls consist of GLP-1 RA users without hospitalization for pancreatitis and were matched to cases in a 1:1 ratio by age category, sex, and residential zip code to minimize confounding variables.  

Results: A total of 6,109 GLP-1 RA users were identified, of which 34 were admitted to the hospital with a primary problem of pancreatitis. This corelates with an 0.56% incidence of pancreatitis. After matching, 50 patients were included; 25 pancreatitis cases and 25 matched controls. The median age was 54 years, and 60% of the cohort was male. The median BMI was 35 kg/m2. The majority of patients were obese (82%) and had type 2 diabetes (78%). Semaglutide (56%) and tirzepatide (32%) were the most common GLP‑1 RAs used. Significant differences between cases and controls were observed for GLP‑1 RA agent distribution (p = 0.004), presence of chronic kidney disease (CKD) (36% vs. 8%; p = 0.017), cholelithiasis/cholecystitis (32% vs. 0%; p = 0.004), and serum creatinine levels (0.99 vs. 0.81 mg/dL; p = 0.038). 

Univariable logistic regression indicated increased odds of pancreatitis associated with CKD (OR 6.47; 95% CI 1.43–46.3; p = 0.027) and higher serum creatinine (OR 5.32; 95% CI 1.32–42.7; p = 0.059). Tirzepatide use was associated with significantly lower odds of pancreatitis (OR 0.11; 95% CI 0.02–0.44; p = 0.003) compared with semaglutide. GLP‑1 RA dose category, HbA1c, triglycerides, alcohol use, smoking status, and baseline metabolic parameters were not significantly associated with pancreatitis. In multivariable regression adjusting for CKD and agent, CKD remained an independent predictor (OR 8.95; p = 0.028), while tirzepatide maintained a protective association (OR 0.10; p = 0.005). 

Conclusions: The incidence of pancreatitis in GLP-1 RA users was 0.56%, which correlates with a higher risk of pancreatitis when compared to 0.03% in the general population. CKD and elevated serum creatinine were significantly associated with increased odds of pancreatitis in GLP-1 RA users, whereas tirzepatide was associated with reduced risk compared with semaglutide.

Moderators
avatar for Aayush Patel

Aayush Patel

Clinical Pharmacy Specialist, Emergency Medicine, Piedmont Columbus Regional Midtown
Presenters
IS
Friday May 1, 2026 9:10am - 9:30am EDT
Athena A
  Internal Medicine (IM), Wake Forest Baptist
  • global Y

9:10am EDT

Evaluation of Thromboprophylaxis Strategies for Orthopedic Surgery Patients
Friday May 1, 2026 9:10am - 9:30am EDT
Athena C
Title: Evaluation of Thromboprophylaxis Strategies for Orthopedic Surgery Patients

Background: Orthopedic surgery patients are high-risk for post-operative venous thromboembolism (VTE) and often require prolonged prophylaxis. Several studies demonstrated that aspirin (ASA) is non-inferior to traditional prophylactic regimens, such as enoxaparin (LMWH), in orthopedic surgery, however these studies are limited regarding therapeutic durations, transitions of care, and inpatient versus outpatient practices. This has led to significant heterogeneity in practice regarding VTE prophylactic agents. This study aims to compare local rates of post-operative VTE and bleeding for patients receiving ASA vs LMWH prophylaxis.

Methods: This retrospective, observational cohort study included adults with surgical femur fractures or femur fractures with prosthetic replacement at Prisma Health Midlands sites between May 2024 and May 2025 receiving either ASA or LMWH for inpatient post-operative VTE prophylaxis. Therapeutic anticoagulation and those with contraindications to either therapy were excluded. The primary outcome was a composite of VTE events or bleeding during post-operative admission. Secondary outcomes included outpatient VTE or bleeding within 60 days, and evaluation of factors that may affect choice of agent. Tertiary outcomes evaluated therapeutic durations, duplications, and transition opportunities.

Results: Rates of the primary outcome of VTE and bleeding during post-operative admissions were not significantly different between groups (adjusted OR 1.05, 95% CI 0.39-2.28), nor were rates of VTE and bleeding from discharge to 60 days post-op (adjusted OR 0.78, 95% CI 0.26-2.40). Provider factors had the largest influence on choice of agent. Half of patients who received LMWH inpatient were switched to ASA on discharge and only 62% of patients had an appropriate stop date on their prophylactic agent.

Conclusion: No significant differences in VTE and bleeding were found between ASA and LMWH groups, both inpatient and post-discharge. Opportunities for improvement exist for several aspects of prophylactic therapy related to transitions of care.
Moderators
DK
Presenters
avatar for Chiara Huber

Chiara Huber

PGY-2 Internal Medicine Resident, Prisma Health Richland - University of South Carolina
I am a PGY-2 Internal Medicine pharmacy resident at Prisma Health Richland - University of South Carolina, with interests in internal medicine, family medicine, and women's health.
Evaluators
avatar for Allie Hale

Allie Hale

Clinical Pharmacist and Residency Program Director, Parkridge Health System
Friday May 1, 2026 9:10am - 9:30am EDT
Athena C
  Internal Medicine (IM), Prisma Health Richland - University of South Carolina
  • global Y

9:30am EDT

Antibiotic escalation strategies after ceftriaxone failure in culture-negative spontaneous bacterial peritonitis (SBP): a single-center retrospective cohort study
Friday May 1, 2026 9:30am - 9:50am EDT
Athena I
Background: Spontaneous bacterial peritonitis (SBP) is the most common bacterial infection among patients with decompensated cirrhosis. Ceftriaxone remains a widely used first line empiric therapy; however, shifts in epidemiology and rising antimicrobial resistance have raised concerns regarding treatment failure in this population. A key challenge in SBP management is that up to 60% of cases are culture negative, necessitating reliance on peritoneal fluid cytology for diagnosis and assessment of therapeutic response. In patients with culture negative SBP who fail to respond to ceftriaxone, evidence-based guidance for antibiotic escalation is lacking, resulting in substantial variability in clinical practice. Evaluation of outcomes in patients with culture negative SBP empirically treated with ceftriaxone may help identify risk factors for treatment failure and inform the effectiveness of commonly employed escalation strategies.
Objective: This study aims to determine the success rates of the following antibiotic escalation strategies used after ceftriaxone failure: carbapenem-sparing regimens (cefepime, or piperacillin-tazobactam), carbapenem regimens, carbapenem-sparing + broad gram-positive coverage (vancomycin, linezolid, or daptomycin), or carbapenem + broad gram-positive coverage. A secondary aim is to identify risk factors associated with ceftriaxone treatment failure in the patient population.
Methods: This is a retrospective cohort study conducted at a tertiary referral hospital from June 2022 to December 2025. Adult patients were included if they had culture negative SBP, defined as an ascitic polymorphonuclear (PMN) count ≥250 cells/µL, were primarily treated with ceftriaxone, and underwent a repeat paracentesis ≥48 hours later to assess treatment response (or had resolution of ascites). Patients were excluded if they had secondary peritonitis, non-cirrhotic peritonitis, or received ≥ 24 hours of alternative antibiotics prior to ceftriaxone. For the primary outcome, we evaluated response rates across the 4 antibiotic escalation groups. Treatment success was defined as a ≥25% reduction in PMN count on repeat paracentesis. For the secondary endpoint, we planned to evaluate risk factors associated with treatment failure and compare patient outcomes.
Results: A total of 69 patients with culture-negative SBP were included. The median age was 55 years (IQR 47–66), 67% were male, and the most common etiology of cirrhosis was alcohol-related (41%). Median MELD-Na score was 22 (IQR 17–28). The median time from admission to SBP diagnosis was 20 hours (IQR 1–69), and 86% of patients received ceftriaxone 2g. Ceftriaxone failure occurred in 5 patients (7.2%). All five received antibiotic escalation: four were treated with a carbapenem-based regimen, and one received cefepime with metronidazole. Among patients with documented PMN response data, reductions ranged from 31% to 89%. Two patients in the ceftriaxone failure group died in-hospital (40%) compared to 4 patients (6%) in the success group. Median hospital length of stay was longer in the failure group (14 days [IQR 10–16] vs. 8 days [IQR 6–18]), as was duration of antibiotic therapy (9 days [IQR 7–13] vs. 5 days [IQR 4–6]). In an exploratory analysis of potential risk factors, nosocomial SBP was identified in 20% of failures and 27% of successes. Prior anti-pseudomonal antibiotic exposure within 90 days was more prevalent among ceftriaxone failures compared to successes (40% vs. 23%). The small sample size precluded formal statistical comparison for all outcomes.
Conclusion: Ceftriaxone failure was uncommon in our cohort of culture-negative SBP, occurring in approximately 7% of patients. Ceftriaxone failure was associated with prolonged hospitalization, extended antibiotic exposure, and higher in-hospital mortality. Prior broad-spectrum antibiotic use emerged as a potential risk factor warranting further investigation in larger cohorts. These findings underscore the need for larger prospective studies to establish evidence-based escalation strategies.
Moderators
JK

Joseph Kohn

PRIS2Prisma Health Richland-University of South CarolinaPGY1
Presenters
MA

Maryam Alarfaj

PGY-1 Resident, AdventHealth Orlando
Evaluators
avatar for Jolie Gallagher

Jolie Gallagher

Clinical Pharmacy Specialist, Critical Care, Emory University Hospital
I am the clinical pharmacy manager at Emory University Hospital.  My background training is in critical care.  My current areas of interest are optimization of transitions of care and pharmacist burnout and resilience.
Friday May 1, 2026 9:30am - 9:50am EDT
Athena I
  Internal Medicine (IM), AdventHealth Orlando
  • global Y

9:30am EDT

Evaluation of the Implementation of a Cardiothoracic Surgery Pre-Operative Anemia Treatment Protocol 
Friday May 1, 2026 9:30am - 9:50am EDT
Olympia 2
Evaluation of the Implementation of a Cardiothoracic Surgery Pre-Operative Anemia Treatment Protocol  

Alyan Saeed, Brendon Banes, Rebecka Hazelwood 
 
Background/Purpose: Patients undergoing cardiothoracic surgery (CTS) frequently present with baseline anemia, which has been associated with increased transfusion requirements, acute kidney injury (AKI), and higher postoperative morbidity and mortality. Prior studies suggest that pre-operative anemia optimization using intravenous iron, erythropoiesis-stimulating agents, and vitamin supplementation may reduce transfusion needs and improve surgical outcomes. In November 2023, Wellstar Kennestone Regional Medical Center (WKRMC) implemented a pre-operative anemia protocol for CTS patients with hemoglobin <12 g/dL; however, its clinical impact has not been formally evaluated. This study aimed to assess the efficacy and safety of the CTS pre-operative anemia protocol.  

Methods: This was an observational, retrospective chart review conducted at WKRMC evaluating adult patients (≥18 years) who underwent CTS between December 1, 2023 and September 1, 2025. Patients with a baseline hemoglobin <12 g/dL were grouped based on whether they received the pre-operative anemia treatment protocol prior to surgery. Patients were followed from three days prior to surgery through seven days post-operatively, hospital discharge, or death, whichever occurred first.   
The primary endpoint was the difference in post-operative hemoglobin levels between patients managed under the protocol and those in the non-protocol group. Secondary endpoints included number of post-operative red blood cell (RBC) units transfused and incidence of AKI within seven days. Safety outcomes included venous thromboembolism, stroke, post-operative infection, and hypersensitivity reactions to IV iron.  
Statistical analyses included paired and independent t-tests, along with Fisher’s exact test for categorical variables.  

Results: A total of 100 patients were included (protocol n=50, non-protocol n=50). Post-operative hemoglobin was similar between patients managed under the protocol and those receiving usual care (8.80 g/dL vs 9.07 g/dL, p=0.25). The mean number of RBC units transfused did not differ significantly between patients managed under the protocol and those receiving usual care (2.28 units vs 2.26 units, p=0.98). Post-operative AKI occurred less frequently in the protocol group compared to the non-protocol group (20% vs 36%, p=0.037). No significant differences were observed regarding the safety end points. There were no cases of IV iron hypersensitivity reactions in the protocol group.  

Conclusion: The pre-operative anemia protocol was associated with a lower incidence of post-operative acute kidney injury in CTS patients, while post-operative hemoglobin levels were similar between groups. These findings suggest that pre-operative anemia management may contribute to improved renal outcomes, despite comparable perioperative hematologic values.  
 

Moderators
avatar for Brian Leith

Brian Leith

Clinical Pharmacist, VA Medical Center
I am currently the emergency medicine and antimicrobial stewardship pharmacist at the VA Medical Center in Fayetteville, NC.
Presenters
avatar for Alyan Saeed

Alyan Saeed

PGY1 Pharmacy Resident, Wellstar Kennestone Regional Medical Center
Evaluators
BK

Brian Knott

Clinical Pharmacy Manager, AdventHealth Winter Park
Friday May 1, 2026 9:30am - 9:50am EDT
Olympia 2
  Internal Medicine (IM), Wellstar Kennestone Regional Medical Center
  • global Y

9:30am EDT

Impact of GLP-1 and GLP-1/GIP Receptor Agonists on Perioperative Glycemic Control in Arthroplasty
Friday May 1, 2026 9:30am - 9:50am EDT
Athena D
Impact of GLP-1 and GLP-1/GIP Receptor Agonists on Perioperative Glycemic Control in Arthroplasty

Authors: Julia Sitek, Charles Hartis, Zachary Klick, Minal Patel, Amit Saha, Ashley Talbott, Sarah Kittner, Emily Schaefer 

Objective: Describe the effect of GLP-1 and GLP-1/GIP receptor agonists on perioperative blood glucose levels. 

Background:  
Obesity and type 2 diabetes (T2DM) are well-established risk factors for osteoarthritis, a leading cause of joint degeneration requiring arthroplasty. Both conditions, along with perioperative hyperglycemia, have been associated with worse postprocedural outcomes and increased risk of mortality.  Glucose-like peptide-1 (GLP-1) and GLP-1/glucose-dependent insulinotropic polypeptide receptor agonists (GLP-1/GIP RA) are becoming increasingly popular due to their indications for T2DM and weight management. Perioperative management of GLP-1 and GLP-1/GIP RAs, specifically the optimal holding duration in surgery, remains controversial. Case reports describing intraoperative aspiration events have prompted recommendations to hold these agents before surgery. Conversely, emerging evidence suggests potential benefits of continuing these medications preoperatively, including improved metabolic outcomes. Given their long-half-lives, these agents may continue to confer glycemic benefits even when held; however, withholding them may increase the risk of perioperative hyperglycemia. Therefore, the purpose of this study is to determine the effect of GLP-1 and GLP-1/GIP RAs on perioperative glycemic control in patients undergoing arthroplasty.  

Methods: 
This multicenter, retrospective, cohort study compared the incidence of perioperative hyperglycemia in patients with T2DM with or without a GLP-1 or GLP-1/GIP RA. Patients 18 years and older with T2DM who underwent primary elective total knee or hip arthroplasty and had available preoperative and postoperative blood glucose data were included in this study. Those with type 1 diabetes, an operative diagnosis of periarticular knee or lower extremity fracture, an American Society of Anesthesiologists classification of 4 or higher, or a need for general anesthesia were excluded. The primary outcome was the percentage of patients with preoperative and postoperative blood glucose levels of 180 mg/dL or greater. Secondary outcomes include any incidence of a hyperglycemic event during admission, 30-day incidence of prosthetics joint infections (PJI) and surgical site infections, incidence of aspiration or regurgitation during procedure, postoperative nausea and vomiting, and 30-day all-cause mortality. Data collection includes baseline demographics, hospitalization characteristics, and drug characteristics, specifically the agent, dose, and time withheld before surgery. Descriptive statistics were used to summarize the incidence of the primary outcome. Inferential statistics were analyzed using Student-t tests for continuous endpoints and Chi-square tests for categorical endpoints. 

Preliminary Results: Among patients undergoing total knee or hip arthroplasty across five hospitals between March 2, 2024 and September 1, 2025, 104 patients were included in the analysis. The cohort was 53.8% female with a mean age of 69 years, mean A1c of 6.5%, and mean BMI of 32.65 kg/m². Preoperatively, 42.3% were on a GLP‑1 or GLP‑1/GIP RA preoperatively. The primary outcome occurred in one (2.3%) patient on a GLP‑1 RA and one (1.7%) patient not receiving a GLP‑1 or GLP‑1/GIP RA preoperatively [OR of 1.37 (95% CI : 0.08 – 22.55, P-Value 0.82)]. The secondary outcome of any event of hyperglycemia during admission occurred in 19 (43.2%) patients receiving a GLP‑1 or GLP-1/GIP RA and 24 (40%) patients not receiving a GLP‑1 or GLP‑1/GIP RA [OR 1.14 ( 95% CI : 0.51 – 2.51, P- Value 0.74)]. Among GLP‑1 or GLP‑1/GIP RA users, the mean duration of medication hold prior to surgery was 10 days. No patients experienced a surgical site infection, PJI, or aspiration/regurgitation event during the study period.  

Conclusion: Holding GLP-1 or GLP-1/GIP RAs for elective total knee or hip arthroplasties does not affect perioperative glycemic control. The benefit of holding GLP-1 or GLP-1/GIP RAs for primary elective arthroplasty may outweigh the risk as no statistically significant increase in incidence of hyperglycemia was observed.
Moderators
avatar for Christele Robinson

Christele Robinson

Emergency Medicine Clinical Pharmacy Specialist, Emory University Hospital
Christele Robinson, PharmD, is board certified in pharmacotherapy. She is a member of the Department of Pharmacy at Emory University Hospital and currently practicing as an Emergency Medicine Clinical Pharmacy Specialist. Dr. Robinson obtained a Bachelor of Science degree at the... Read More →
Presenters
avatar for Julia Sitek

Julia Sitek

PGY1 Pharmacy Resident, Atrium Health Wake Forest Baptist
Evaluators
avatar for Cody Parker

Cody Parker

Clinical Pharmacy Specialist, St. Joseph's/Candler
Dr. Cody Parker is the PGY1 Pharmacy Residency Program Director at St. Joseph's/Candler in Savannah, GA. He received his Doctor of Pharmacy from the University of Georgia and completed a Postgraduate Year One (PGY1) Pharmacy Practice Residency at St. Joseph’s/Candler. Dr. Parker is a Clinical Pharmacy Sp... Read More →
Friday May 1, 2026 9:30am - 9:50am EDT
Athena D
  Internal Medicine (IM), Wake Forest Baptist
  • global Y

9:30am EDT

Safety of Intravenous Push Lacosamide Compared with Intravenous Piggyback at a Community Hospital
Friday May 1, 2026 9:30am - 9:50am EDT
Athena C
Authors: Lauren Baugh, Karen Babb 

Background:
Lacosamide is an FDA approved medication for the treatment of focal onset seizures and primary generalized tonic-clonic seizures and is also used off-label for status epilepticus.1 The Neurocritical Critical Care Guidelines for the Evaluation and Management of Status Epilepticus propose 200 mg lacosamide given over 15 minutes as an alternative for rapid administration, while acknowledging the risk for possible adverse effects, such as hypotension or QT prolongation.2 Recent studies suggest an increased incidence of cardiovascular, neurological, and infusion site related adverse events with intravenous push as compared to intravenous piggyback administration.4

This study will assess the incidence of adverse events associated with intravenous push compared to intravenous piggyback lacosamide within our institution.

Methodology:
This was a single-center retrospective cohort analysis. Chart review was utilized to compare patients that received lacosamide via intravenous piggyback or push administration. Included in the study were adult patients 18 years old or older that received at least one dose of IV push or IV piggyback lacosamide from May 1, 2024 - October 31, 2024 and December 1, 2024 - May 31, 2025. Exclusion criteria was doses greater than 400 milligrams. The primary outcome was incidence of adverse drug events (hypotension, bradycardia, infusion site reactions, sedation) in patients receiving intravenous push lacosamide compared to those that receive intravenous piggyback lacosamide. Secondary outcomes reviewed time to administration of intravenous push lacosamide compared to that of intravenous piggyback lacosamide.

Results:
A total of 110 patients were included in the study, with 50 in the intravenous piggyback group and 60 in the intravenous push group. Baseline characteristics, such as age, sex, weight, race, home lacosamide use, and pre-existing comorbidities, were comparable between the two cohorts. Of the 110 patients, a total of 747 doses were observed, with 379 doses given intravenous push and 368 given intravenous piggyback. Of the primary outcomes, incidence of bradycardia, hypotension, medication related sedation, and administration site reaction, there were no statistically significant differences. The median time to first dose administration was 50 minutes in the intravenous push group and 62 minutes in the intravenous piggyback group.

Conclusion:
This study highlights the advantages of administering intravenous push lacosamide without increased risk of adverse events. The findings indicate that the incidence of adverse events was not higher than that seen in the intravenous piggyback administration, while providing shorter time to first dose administration. However, limitations of the study should be considered in the interpretation of the results. The primary limitation of this study was the missing documentation of heart rate, blood pressure, and sedation scores with each dose of lacosamide given. Furthermore, findings should be interpreted in light of the fact that patients requiring hospitalization are often critically ill and exposed to a multitude of factors which could independently contribute to adverse outcomes rather than solely lacosamide administration. In the future, the findings should be presented to the pharmacy and therapeutics committee to further support the current implemented practice. The results of this study should also encourage education on the importance of standardized nursing documentation.

[email protected]
Moderators
DK
Presenters
avatar for Lauren Baugh

Lauren Baugh

PGY1 Pharmacy Resident, CommonSpirit Memorial
My name is Lauren Baugh. I am currently a PGY1 resident at CHI Memorial in Chattanooga, Tennessee. I graduated from the University of Georgia College of Pharmacy with my PharmD in 2025. I will be staying on as clinical pharmacist at Memorial after completion of my PGY1 residency.
... Read More →
Evaluators
avatar for Allie Hale

Allie Hale

Clinical Pharmacist and Residency Program Director, Parkridge Health System
Friday May 1, 2026 9:30am - 9:50am EDT
Athena C
  Internal Medicine (IM), CHI Memorial
  • global Y

9:50am EDT

Impact of Integrating the BioFire® Meningitis/ Encephalitis Panel (MEP) with Antimicrobial Stewardship in a Non-Teaching Community Hospital
Friday May 1, 2026 9:50am - 10:10am EDT
Parthenon 2
Title: Title: Impact of Integrating the BioFire® Meningitis/ Encephalitis (ME) Panel with Antimicrobial Stewardship in a Non-Teaching Community Hospital

Investigators: Ashtyn Keller; Brad Crane; Emily Duncan; Stephanie Grimes; Joy (Abby) Bussey 

Study Location: Prisma Health Blount Memorial Hospital, Maryville, TN – Department of Pharmacy 

Background: Limited data exists on the clinical and financial impact of rapid cerebrospinal fluid (CSF) diagnostic testing in non-academic community hospitals. This study evaluated the effect of implementing the BioFire® MEP on patient outcomes and hospital resource utilization.  

Methods: This IRB-approved, single-center, retrospective cohort study included adults hospitalized from July 2020 through June 2025 with an identified CSF culture ordered. Exclusion criteria were if less than 18 years old, test cancellation or non-completion, transfer to another facility, repeat CSF specimens from the same patient or infection, or treated outpatient only. The primary outcome was time to optimal antimicrobial therapy in patients without the BioFire® MEP or with the BioFire® MEP. Secondary outcomes compared duration of antimicrobial therapy, hospital length of stay, and hospital costs per visit. Student’s t-tests were used with significance defined as p < 0.05. 

Results: A total of one hundred and twenty-one patients were included: eighty-seven patients (72%) did not utilize the BioFire® MEP, and thirty-four patients (28%) utilized the BioFire® MEP. Median time to optimal antimicrobial therapy without the BioFire® MEP was 3.0 days compared to 2.0 days with the BioFire® MEP (absolute difference 1 day; 95% CI 0.004 to 1.96; p=0.04). Mean duration of antimicrobial therapy without the BioFire® MEP was 4.0 days compared to 2.9 days with the BioFire® MEP (absolute difference 1.1; 95% CI -2.72 to 0.56; p=0.19). Median hospital length of stay without the BioFire® MEP was 6.0 days compared to 4.5 days with the BioFire® MEP (absolute difference 1.5; 95% CI -1.74 to 4.74; p=0.36). Median hospital costs per visit without the BioFire® MEP were $8,456 compared to $9,854 with the BioFire® MEP (absolute difference $1,398). 

Conclusion: In conclusion, this retrospective cohort study in a non-academic, community hospital, demonstrated that the implementation of the BioFire® MEP was associated with a significantly significant reduction in time to optimal antimicrobial therapy and potentially shorter antimicrobial duration and hospital length of stay. Additional large-scale studies are recommended to confirm these findings.

Moderators
CM
Presenters
avatar for Ashtyn Keller
Evaluators
CT

Christina Thurber

PGY-1 Residency Program Coordinator
Friday May 1, 2026 9:50am - 10:10am EDT
Parthenon 2
  Internal Medicine (IM), Blount Memorial Hospital

9:50am EDT

Impact of the Intravenous Lorazepam Shortage on Alcohol Withdrawal Treatment in the ICU
Friday May 1, 2026 9:50am - 10:10am EDT
Olympia 2
Background: The American Society of Addiction Medicine guidelines recommend benzodiazepines as first-line treatment for moderate-severe alcohol withdrawal syndrome (AWS). Intravenous (IV) lorazepam is a first-line therapy for AWS at Emory Healthcare (EHC) to prevent complications such as seizures and delirium tremens. The quick onset, half-life, and lack of metabolites make IV lorazepam a desirable agent for AWS. There have been intermittent shortages of IV lorazepam, with the most recent shortage beginning in May 2025. In response, EHC built an electronic alert as a soft stop for all IV lorazepam orders to notify providers of the shortage and recommend alternatives. In addition, the AWS order set was modified to replace IV lorazepam with IV midazolam. The goal of this study was to understand medication utilization patterns during this shortage and provide guidance for future shortages.  

Methods: This study was a multi-center, retrospective chart review of adult patients receiving treatment for moderate-severe AWS from 1/30/2025 to 9/7/2025 in the ICU. Pre-shortage and post-shortage groups were determined based on IV lorazepam shortage alerts, which began in EPIC on 5/20/2025. The primary objective was to examine medication utilization patterns of AWS before and after the alert was implemented. Evaluation of this endpoint was determined by medication name, strength, route, frequency, and duration for 48 hours after the alcohol withdrawal order set was active. Secondary objectives measured safety and clinical outcomes and included respiratory rates, hypotension, and changes in scores of Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA), length of stay, mortality, 30-day readmissions, respectively. Data was analyzed using descriptive statistics, t-test, and Mann-Whitney U test.

Results: There were 127 patients in the pre-shortage group and 152 patients in the post-shortage group. Baseline characteristics were similar between groups. The average baseline CIWA scores were similar with first CIWA ≥8 13.44 pre-shortage versus 12.86 post-shortage. IV lorazepam doses were higher in the first 12 hours of the AWS order set ordering time. In the post-shortage group, there was a greater decrease in IV lorazepam dose 12-24 hours post-alert (63.14% versus 43.72%). IV lorazepam orders trended down (57% versus 47%, p-value 0.097), and patients prescribed oral lorazepam trended up (23% versus 32%, p-value 0.081). More patients in the post-shortage group were prescribed chlordiazepoxide (5 versus 16 patients, p-value 0.038) and midazolam (20 versus 45 patients, p-value 0.006). Phenobarbital use did not change significantly (86 versus 89 patients, p-value 0.115). First CIWA <8, was similar at 4.37 pre-shortage versus 3.84 post-shortage. The average time to CIWA score <8 from the first score ≥8 was greater in the pre-shortage group 9 hours and 13 minutes compared to 8 hours and 37 minutes (p-value 0.205). Average hospital length of stay (12.39 versus 11.07 days, p-value 0.290), average ICU length of stay (5.28 versus 5.44 days, p-value 0.725), and mortality (5 versus 7 patients, p-value 0.784) were similar between the two groups. Readmission within 30 days and respiratory depression were higher in the post-shortage group (12% versus 18%, p-value 0.166 and 67% versus 73%, p-value 0.267, respectively).

Conclusion: Following IV lorazepam alerts, medication utilization shifted towards chlordiazepoxide and midazolam. The average cumulative dose of IV lorazepam decreased more in the post-shortage group after the first 12 hours. Phenobarbital use may not have changed due to provider practice styles and the recommended alternatives. This was a retrospective study, alerts for alternative agents could be bypassed, and medications listed may have been used for other indications. Future direction includes evaluating alternative medication usage patterns with a developed phenobarbital order set. A comparative analysis focused on adverse drug events and efficacy may further shape treatment.

Moderators
avatar for Brian Leith

Brian Leith

Clinical Pharmacist, VA Medical Center
I am currently the emergency medicine and antimicrobial stewardship pharmacist at the VA Medical Center in Fayetteville, NC.
Presenters
AL

Anatolia Legaspi

PGY-1 Resident, Emory University Hospital Midtown
Evaluators
BK

Brian Knott

Clinical Pharmacy Manager, AdventHealth Winter Park
Friday May 1, 2026 9:50am - 10:10am EDT
Olympia 2
  Internal Medicine (IM), Emory University Hospital Midtown
  • global Y

9:50am EDT

Resident Presentation - Katherine Albus
Friday May 1, 2026 9:50am - 10:10am EDT
Athena H
Linezolid as Empiric Therapy for Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia: A Retrospective Cohort Analysis of Clinical Outcomes  
Katherine Albus, Kellee Geren, Samantha Walker, Brandon Hawkins 
The University of Tennessee Medical Center, Knoxville, TN 
 
Background/Purpose: Methicillin-resistant Staphylococcus aureus (MRSA) remains one of the most difficult-to-treat Staphylococcus species worldwide, with mortality exceeding 20%. Vancomycin (VAN) or daptomycin (DAP) are considered first-line empiric therapies for MRSA bacteremia.  Small subgroup analyses have suggested improved survival and faster bacteremia clearance with linezolid (LZD) versus glycopeptides, yet its role is largely unclear. This study aimed to compare the effectiveness of LZD versus VAN or DAP in patients with MRSA bacteremia.   
 
Methodology: This single-center, retrospective, observational cohort study included hospitalized between December 2017 and June 2024. The primary outcome was a composite of 60-day all-cause mortality and bacteremia persisting greater than 7 days. Secondary outcomes included the individual components of the composite outcome, duration of antimicrobial therapy, duration of bacteremia, and ICU admission. Eligible patients were 18 years of age or older, had at least one MRSA-positive blood culture, and received empiric LZD, VAN, or DAP for at least 48 hours from culture collection. VAN and DAP were assessed as composite groups. Exclusion criteria included death or transition to hospice within 48 hours of culture collection, failure to receive a study antibiotic within 3 hours of culture, receipt of a comparator antimicrobial for more than 24 hours, or lack of susceptibility to the empiric agent. 
 
Results: There was no difference in patients receiving LZD or VAN/DAP in the primary composite outcome (0% LZD vs. 43.8% VAN/DAP; P = 0.074) or the individual components of 60-day all-cause mortality (0%  LZD vs. 19.8%  VAN/DAP; P = 0.580) and persistent bacteremia greater than 7 days (0% LZD vs. 32.6% VAN/DAP; P = 0.319). The median duration of antimicrobial therapy was numerically shorter in the LZD group compared with the VAN/DAP group (19.5 days vs. 43 days, respectively), though this was not significant (P = 0.143). ICU admission rates during treatment were comparable between groups (20% LZD vs. 38% VAN/DAP; P = 0.646). The duration of bacteremia was significantly shorter among patients treated with LZD compared to VAN/DAP, with median durations of 2.4 days and 5.5 days, respectively (P = 0.036). 
 
Conclusions: In a small sample, empiric LZD for MRSA bacteremia demonstrated comparable rates of 60-day mortality and persistent bacteremia compared with VAN or DAP. LZD demonstrated a significantly shorter duration of bacteremia than VAN/DAP, although these findings may be due to LZD use in less complicated infections. These results, when considered alongside existing clinical and pharmacologic evidence, support further investigation of LZD as a potential first-line option for MRSA bacteremia. Larger, prospective studies are needed to better define the role of LZD in uncomplicated, Gram positive infections with Gram negative coverage where appropriate.  

Link: https://docs.google.com/document/d/e/2PACX-1vQzRhZffUvSQUgtz-e88XOkxVPWlCJON2KHAtHhLXttKCpq05YARaPn9673tC8gAzP64x3Ss3WU3wYN/pub
Moderators
AC
Presenters
KA

Katherine Albus

Katie Albus, PharmD is a PGY1 at the University of Tennessee Medical Center in Knoxville, Tennessee. She completed her pharmacy schooling at Virginia Commonwealth University and plans to continue her education through a PGY2 in critical care at Carilion Roanoke Memorial Hospital in... Read More →
Evaluators
avatar for Anh Nguyen

Anh Nguyen

Clinical Pharmacy Specialist, Emory Decatur Hospital
I’m a Board‑Certified Critical Care Pharmacy Specialist with a passion for taking care of some of the sickest patients in the hospital. I’ve worked in both intermediate and intensive care settings, where every day brings a new challenge and a new opportunity to make a meaningful... Read More →
Friday May 1, 2026 9:50am - 10:10am EDT
Athena H
  Internal Medicine (IM), University of Tennessee Medical Center
  • global Y

10:20am EDT

Evaluating the Impact of ACEi or ARB Reinitiation versus Discontinuation Post Hospitalization with Acute Kidney Injury on Patient Outcomes
Friday May 1, 2026 10:20am - 10:40am EDT
Athena H
Angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) provide cardiovascular and renal protections across hypertension, chronic kidney disease, and heart failure populations, yet are often held during episodes of acute kidney injury (AKI). Optimal timing of post-AKI reinitiation remains uncertain. We aimed to compare outcomes among patients whose ACEi or ARB therapy was restarted at different times.   
 
We conducted a single center, retrospective cohort study of adult inpatients with AKI whose ACEi, ARB, or ARNI therapy was held ≥24 hours during hospitalization. Patients were categorized into 3 groups depending on whether therapy was restarted during hospitalization, restarted upon discharge, or not continued at discharge. The primary endpoint was complete renal recovery at 90 days. Secondary endpoints were AKI readmission rates within 90 days of discharge, cardiovascular events and all-cause mortality at 12 months, and time to treatment reinitiation in group 3. 
 
Among 148 patients (Group 1, n=41; Group 2, n=52; Group 3, n=55), there was no significant difference across groups in renal recovery at 90 days (73.2%, 59.6%, 67.3%, respectively; p=0.13). AKI readmission rates within 90 days (9.8%, 19.2%, 9.1%, respectively; p=0.25), cardiovascular events within 12 months (17.1%, 7.7%, 18.2%, respectively; p=0.22), and all-cause mortality within 12 months (12.2%, 5.8%, 7.3%, respectively; p=0.53) were similar across groups. Median (SD) time to reinitiation in group 3 was 60 ±94 days (p=0.049). 
 
Early reinitiation of ACEi or ARB after AKI did not worsen renal recovery at 90 days or increase adverse events. These findings support timely reinitiation with appropriate monitoring.  

Moderators
TC
Presenters
avatar for Leslie Phillips

Leslie Phillips

PGY-2 Pharmacotherapy Pharmacy Resident, University of Tennessee Medical Center
Dr. Leslie A. Phillips is a PGY-2 Pharmacotherapy resident at the University of Tennessee Medical Center. Originally from Atlanta, Georgia, she earned her Bachelor of Science in Chemistry from Kennesaw State University and a Doctor of Pharmacy degree from The University of Georgia... Read More →
Evaluators
avatar for Yona Roberts

Yona Roberts

RPD/Clinical Pharmacy Manager, WSGA1Wellstar Cobb HospitalPGY1
Yona Roberts earned a Doctor of Pharmacy degree from Florida Agricultural and Mechanical University in Tallahassee, Florida.  She went on to complete a Pharmacy Practice Residency through Mercer University at DeKalb Medical Center in Atlanta, Georgia.  After completion of her residency... Read More →
Friday May 1, 2026 10:20am - 10:40am EDT
Athena H
  Internal Medicine (IM), University of Tennessee Medical Center
  • global Y

10:20am EDT

Evaluating the Outcomes of Pharmacist Driven Interventions in a Geographic Rounding Pilot at a Large Community Hospital
Friday May 1, 2026 10:20am - 10:40am EDT
Athena G
Oksana Buksa, PharmD, April Williams, PharmD, BCPS, Michele Moseley, PharmD, BCPS, Anna Cross, PharmD, Erik Roberts, CPhT
Huntsville Hospital – Huntsville, Alabama

Purpose/Background:
Huntsville Hospital has announced the implementation of a hospitalist-led geographic rounding pilot that began on October 1st, 2025, which was designed to allow providers to care for patients within the same inpatient unit, thereby maximizing efficiency and improving continuity of care, with the goal of decreasing hospital length of stay. The service currently spans three inpatient floors and encourages hospitalists to prioritize rounding on patients who are discharging home first, followed by those discharging to post-acute care facilities, and subsequently, all other patients remaining.  In addition, Huntsville Hospital has a robust Transitions of Care team that includes pharmacists who play an integral role in facilitating patient discharges by reviewing discharge medication reconciliation and communicating with providers to clarify medication orders as needed, as well as providing essential medication education to patients. The purpose of this research is to evaluate the outcomes of pharmacist-driven interventions within a hospitalist-led geographic rounding model focused on improving patient outcomes and coordination of care. If the results from this pilot demonstrate positive outcomes and are well received by participating rounding physicians, then the program may be expanded to additional inpatient units within the hospital.

Methodology:
This single center, Institutional Review Committee (IRC)–approved pre and post analysis was designed to evaluate the primary outcome, defined as the time from discharge order placement to patient discharge from the hospital. Secondary outcomes include hospital length of stay, total number of discharge reconciliations reviewed by the Transitions of Care pharmacy team per month, average time required to complete individual discharge interventions, and the total number of discharges classified as having significant clinical impact. Pre-implementation data was collected from the following dates: July 1st-September 30th, 2025. Post implementation data was collected from patients discharged by physicians participating in the rounding pilot between November 1st, 2025 and January 31st, 2026. Outcomes were compared between the three month pre and post implementation periods. Baseline characteristics include age, race, sex, and discharge disposition. Statistical analysis was conducted to evaluate categorical and continuous data using descriptive statistics. These analyses aim to evaluate the potential impact of the rounding pilot and pharmacist-driven discharge processes on the timeliness of hospital discharge and overall patient care outcomes.

Results:
A total of 1,201 discharges occurred during the post-implementation period, of which 418 patients (75.3%) were included in the rounding pilot with documented Transitions of Care (TOC) discharge notes. The primary outcome, the time from discharge order placement to patient discharge from facility, decreased overall in the post-implementation period. However, when stratified by discharge disposition, this time increased for home/self-care patients but not for facility discharges, which may be attributable to the higher proportion of facility discharges in the post period, requiring more complex coordination of care. Additionally, duplicate discharge orders were identified, which may have prolonged discharge timing, as these patients were not ready for discharge at the time of initial order placement. For secondary outcomes, patient length of stay did not decrease in the post-implementation period, which could be impacted by seasonal variability and differences in patient acuity between the pre- and post-implementation groups. The average time to complete TOC discharge notes and the number of interventions with significant clinical impact remained similar between groups.  

Conclusion:
Although the results from this study did not demonstrate a consistent improvement in the primary outcome across all discharge dispositions, geographic rounding can still enhance patient care through improved coordination and interdisciplinary communication. The integration of Transitions of Care pharmacists into geographic rounding supports earlier involvement in the discharge process and facilitates optimized medication reconciliation, discharge planning, and patient education.
Moderators
TO
Presenters
avatar for Oksana Buksa
Evaluators
TB
Friday May 1, 2026 10:20am - 10:40am EDT
Athena G
  Internal Medicine (IM), Huntsville Hospital
  • global Y

10:20am EDT

Impact of Education on Subcutaneous Electronic Glucose Management System Usage in a Community Hospital - Makenzie Foster
Friday May 1, 2026 10:20am - 10:40am EDT
Athena D
Impact of Education on Subcutaneous Electronic Glucose Management System Usage in a Community Hospital
Makenzie Foster & Taylor Riedel-Rogers

Background:
The American Diabetes Association recommends using basal/bolus insulin for the management of hyperglycemia in non-critically ill hospitalized patients.1 The incidence of hypoglycemia while on a basal/bolus insulin regimen in the hospital setting can be as high as 33%.2 A hypoglycemic event during admission has been shown to increase mortality rates, complications, and hospital length of stay.1 The use of electronic glucose management systems (eGMS) in hospitalized patients has been shown to decrease incidence of hypoglycemia compared to those managed solely by providers.3 Additionally, patients managed by eGMS were found to have a higher percentage of blood glucose levels within target range compared to traditional provider management.4 Baptist Health Lexington implemented a subcutaneous glucose management system in 2022. This study aims to assess the duration of subcutaneous eGMS use prior to and following a single session of subcutaneous eGMS education to pharmacists and nurses at Baptist Health Lexington.

Methods:
This study is an IRB-approved study where a pre-post analysis of subcutaneous eGMS duration is conducted following a single session of eGMS education. A retrospective review of patient charts will be conducted on patients who received blood glucose management through eGMS at Baptist Health Lexington prior to implementing a single session of pharmacist and nurse education from 03/01/2025 to 08/31/2025. Additionally, a retrospective review of patient charts will be conducted following the implementation of eGMS education from 10/01/2025 to 03/31/2026 for those managed by subcutaneous eGMS. The primary endpoint of this study is the duration of subcutaneous eGMS use following a single session of pharmacist and nurse eGMS education. The secondary endpoints are the number of patients transitioning from intravenous to subcutaneous eGMS, the incidence of hypoglycemic events and the total number of patients managed by subcutaneous eGMS.

Results: 
The retrospective analysis identified 101 patients in the pre-intervention group and 66 patients in the post-intervention group. Following a single session of pharmacist and nurse subcutaneous eGMS education, the duration of subcutaneous eGMS was found to be statistically significant (p-value 0.025). The incidence of hypoglycemic events was 7 out of 101 patients in the pre-intervention group and 3 out of 66 patients in the post-intervention group (p-value 0.73). The number of patients transitioning from intravenous to subcutaneous therapy was 33 out of 101 in the pre-intervention group and 19 out of 66 in the post-intervention group. 

Conclusion: 
Pharmacist and nurse subcutaneous eGMS education resulted in a statistically significant increase in the duration of subcutaneous eGMS therapy. However, a statistically significant difference was not found for the incidence of hypoglycemic events or number of patients transitioning from intravenous to subcutaneous therapy following a single session of pharmacist and nurse education. There are still opportunities for improvement in the utilization of subcutaneous eGMS at Baptist Health Lexington and further education on eGMS is currently being pursued at a system level.

References:
1. El Sayed, Nuha A., et al. “16. diabetes care in the hospital: standards of care indiabetes—2024.” Diabetes Care, vol. 47, no. Supplement_1, 11 Dec. 2023, https://doi.org/10.2337/dc24-s016.
2. Aloi, Joseph, et al. “Comparison of an electronic glycemic management system versus provider-managed subcutaneous basal bolus insulin therapy in the hospital setting.” Journal of Diabetes Science and Technology, vol. 11, no. 1, 25 Sept. 2016, pp.12–16, https://doi.org/10.1177/1932296816664746.
3. Bouldin, Mary Grace, et al. “Evaluation of the efficacy and safety of an EGLYCEMIC management system in a community hospital setting.” Journal of Diabetes Science and Technology, vol. 15, no. 2, 16 Dec. 2020, pp. 236–241, https://doi.org/10.1177/1932296820980026.

Resident Contact Information:
Makenzie Foster, PGY1 Pharmacy Resident
Email: [email protected]
Moderators
avatar for Jessica Ringler
Presenters
avatar for Makenzie Foster

Makenzie Foster

PGY1 Pharmacy Resident
My name is Makenzie Foster, and I am a PGY1 pharmacy resident at Baptist Health Lexington. I graduated with my Doctor of Pharmacy from the University of Kentucky College of Pharmacy in 2025, and I completed my pre-pharmacy education at the University of Kentucky in 2021. I will be... Read More →
Evaluators
avatar for Carrie Callahan

Carrie Callahan

Internal Medicine (IM) Specialist, PGY2 IM RPD, Emory University Hospital


Friday May 1, 2026 10:20am - 10:40am EDT
Athena D
  Internal Medicine (IM), Baptist Health Lexington

10:20am EDT

Optimizing Postoperative Pain Management in Total Hip Arthroplasty with Liposomal Bupivacaine
Friday May 1, 2026 10:20am - 10:40am EDT
Athena C
Primary Author: Jessica Kennedy

Co-Authors: Taylor Burich; Michael Brandon Hardison; Jeremy Walley

Title: Optimizing Postoperative Pain Management in Total Hip Arthroplasty with Liposomal Bupivacaine

Background: Total hip arthroplasty (THA) is associated with significant postoperative pain, prolonged hospitalizations, early mobilization, and increased opioid utilization.  In the United States, over 500,000 THA occur every year and can often lead to opioid over prescribing. Effective postoperative pain control is critical in THA to facilitate early mobilization, reduce opioid consumption, and support recovery. Liposomal bupivacaine is Food and Drug Administration (FDA) approved as a long-acting local and regional anesthetic. The purpose of this study is to assess liposomal bupivacaine utilization as a part of a multimodal analgesia approach to improve pain control and reduce opioid consumption following THA.

Methods: This study aims to evaluate the efficacy of liposomal bupivacaine as a part of a multimodal analgesic approach in patients undergoing THA. Data will be collected through patient interviews via a standardized questionnaire to determine opioid utilization, pain score, and time to regain mobility and sensation. Patients included in this study are those 18 years or older who underwent THA with liposomal bupivacaine utilization. Exclusion criteria will be patients receiving liposomal bupivacaine for any other indication and those with a documented hypersensitivity or allergic reaction to liposomal bupivacaine or any of its analogs. The primary objective of this study is to examine opioid requirements after surgery as well as pain scores in patients who received liposomal bupivacaine. Secondary objectives will include the time to regain mobility and sensation post-operatively, as well as cost savings from a reduction in length of stay.  

Results: The primary endpoint saw the pain scores of those who received liposomal bupivacaine 17 individuals fell within mild pain scores (0-3), and 5 within the moderate pain scores (4-6). Compared to the standard of care group who had 13,16,13 in their mild, moderate, and severe pain scores. As for opioid requirements there was change of an increase in usage within both groups, however, those who received liposomal bupivacaine required19 mg compared to standard of care which required on average 27.1 mg. As for secondary endpoints  there was no difference within the mobility and sensation as both groups were moving about every hour at a minimum. Analysis for cost is still in progress. 

Conclusion: Utilization of liposomal bupivacaine provides a multimodal approach for postoperative pain management in THA. Those individuals who received liposomal bupivacaine had a reduction in pain scores and opioid usage when compared to the standard of care. 

Moderators
BW
Presenters
avatar for Jessica Kennedy
Evaluators
avatar for Devon Burhoe
Friday May 1, 2026 10:20am - 10:40am EDT
Athena C
  Internal Medicine (IM), Cookeville Regional Medical Center
  • global Y

10:40am EDT

Evaluating Pharmacist Monitoring in Patients with Euglycemic Diabetic Ketoacidosis Prescribed Sodium-Glucose Cotransporter-2 inhibitors Prior to Admission
Friday May 1, 2026 10:40am - 11:00am EDT
Athena D
Purpose/Background: Euglycemic diabetic ketoacidosis (EDKA) falls under the umbrella of diabetic ketoacidosis (DKA) and can occur in patients with type 1 or type 2 diabetes mellitus. EDKA is thought to be caused by a renal threshold for glucosuria that is lower due to increased gluconeogenesis and free fatty acid metabolism. A common medication class prescribed to patients with diabetes mellitus, sodium-glucose cotransporter-2 (SGLT2) inhibitors, are thought to inhibit both glucose and sodium resorption at the renal proximal tubule which leads ultimately to glucosuria and negative fluid balances. These mechanisms lead to a loss of bicarbonate and cause ketogenesis, which ultimately leads to EDKA. The purpose of this study is to evaluate the effect of pharmacy monitoring on the appropriate clinical courses in patients on sodium-glucose cotransporter-2 inhibitors who are admitted for euglycemic diabetic ketoacidosis in a regional medical center.
Methodology: Data will be collected based on a pre- and post-evaluation of the electronic medical record. Prospective data collection will be done through a daily report of patients that are greater than or equal to 18 years old, admitted to CaroMont Regional Medical center, have an SGLT2 inhibitor on their prior to admission medication list, and have a diagnosis of diabetes on their hospital problem list. Patients will be excluded if they are less than 18 years old, have no diagnosis of diabetes mellitus, have a glucose on admission that is > 250 mg/dL, are pregnant or incarcerated. Once the daily report is run, the clinical pharmacist will ensure the correct lab values and medications are ordered. If a patient meets EDKA criteria, a clinical pharmacist will evaluate the need for additional evaluation, including β-hydroxybutyrate, to strengthen diagnostic criteria and guide potential treatment. Retrospective data collection will be done through the collection of pre-specified criteria and analysis of the treatment course in patients that presented with EDKA. Both data sets will be taken from the same months, one year apart. The data sets will be compared to assess the effectiveness of pharmacy interventions. The primary endpoint of the study will be the time to resolution of euglycemic diabetic ketoacidosis. Time to insulin infusion, length of stay, number of admissions, and number of clinical pharmacist interventions will also be assessed.  
Results: Pending 
Conclusions: Pending
Presentation Objective: To describe the benefit of pharmacy interventions in the treatment course of patients that present with euglycemic diabetic ketoacidosis secondary to receiving sodium-glucose cotransporter-2 inhibitors for management of their diabetes prior to admission.  
Self-Assessment: What are the criteria for a diagnosis of euglycemic diabetic ketoacidosis?
Authors: Rylee Williams, Joe Norton, Joanna Nixon
Moderators
avatar for Jessica Ringler
Presenters
avatar for Rylee Williams

Rylee Williams

PGY-1 Resident, CaroMont Regional Medical Center
Evaluators
avatar for Carrie Callahan

Carrie Callahan

Internal Medicine (IM) Specialist, PGY2 IM RPD, Emory University Hospital


Friday May 1, 2026 10:40am - 11:00am EDT
Athena D
  Internal Medicine (IM), CaroMont Regional Medical Center

10:40am EDT

Evaluation of Prophylactic Anticoagulation usage within the Central Alabama Veterans Health Care System Inpatient Setting
Friday May 1, 2026 10:40am - 11:00am EDT
Athena C
Primary Author: Charles Pitts
Co-Authors: Hope Allen, Brittany Till, Morgan Moulton, Perry Thompson, Walter Minger, Tiffany Lyght

Background: Venous thromboembolism (VTE) is a common cardiovascular diagnosis, with many cases linked to recent hospitalizations. Prophylactic anticoagulation is used to prevent VTE, guided by patient risk factors. Risk Assessment Models (RAMs), such as the Padua VTE RAM, help determine when VTE prophylaxis is appropriate or should be avoided due to bleed risk, as recommended by the American Society of Hematology. This project was designed to evaluate the current utilization of prophylactic anticoagulation using the Padua VTE RAM to determine its appropriateness in patients admitted to the inpatient setting. According to the Padua RAM, scores of 4 or more are indicative of high VTE risk and should receive anticoagulation.

Methods: This project was a retrospective, observational review of Veterans' charts who received prophylactic anticoagulation in the inpatient setting within the Central Alabama Veterans Health Care System (CAVHCS). Data collected included Veteran demographics, active prescriptions, ICD codes, recent surgeries, age, body mass index (BMI), birth sex, kidney function, presence of a central venous catheter, critical care admissions, liver function tests, platelet counts, and recent bleeding events. The data was compiled in a de-identified Microsoft Excel spreadsheet for analysis. The primary outcome assessed was the percentage of Veterans appropriately placed on prophylactic anticoagulation based on inclusion/exclusion criteria. Secondary outcomes included the number of admitted Veterans receiving prophylactic anticoagulation who experienced bleeding-related events and thrombosis-related events.

Results: One hundred Veteran charts were evaluated for this project. Of the evaluated charts, prophylactic anticoagulation was appropriately administered or withheld in 53 Veterans and prophylactic anticoagulation was inappropriately administered or withheld in 47 Veterans based on their individual Padua RAM scores. Of the 47 Veterans, 45 received inappropriate prophylactic anticoagulation and two Veterans had prophylactic anticoagulation withheld inappropriately. None of the Veterans evaluated experienced bleed or thrombosis-related events.

Conclusions: Nearly 50% of Veterans reviewed had anticoagulation inappropriately administered or withheld while admitted. While this evaluation did not find any bleed or thrombosis-related events, the current anticoagulation prescribing trends leave room for improvement. The creation of a policy to standardize the criteria for VTE prophylaxis could increase appropriate anticoagulation prescribing patterns within the CAVHCS inpatient setting. This project also exposes an area of Veteran healthcare that Clinical Pharmacy Practitioners could assist in optimizing and monitoring.
Moderators
BW
Presenters
avatar for Charles Pitts

Charles Pitts

PGY1 Pharmacy Resident, Central Alabama Veterans Healthcare System
Charlie Pitts is currently a PGY1 pharmacy resident with the Central Alabama Veterans Healthcare System in Montgomery, Alabama. He is originally from Hopkinsville, Kentucky, but has been a resident of Alabama since starting pharmacy school at the Samford University McWhorter School... Read More →
Evaluators
avatar for Devon Burhoe
Friday May 1, 2026 10:40am - 11:00am EDT
Athena C
  Internal Medicine (IM), VA-Montgomery, AL-Central Alabama Veterans Health Care System
  • global Y

10:40am EDT

Evaluation of the Impact of Lower Extremity Wound Order Set Revision
Friday May 1, 2026 10:40am - 11:00am EDT
Athena G
Title: Evaluation of the impact of lower extremity wound order set revision

Authors: Katie Hindman, Adesuwa Utomwen, Dustin Zeigler, Jeremy Frens

Objective: Discuss the utilization of an updated lower extremity wound order set

Self-Assessment Question: 
  • True or False: The updated lower extremity wound order set had numerically increased adherence compared to the prior order set.

Background: Diabetic foot infections (DFIs) pose a significant threat to quality of life, being a leading cause of non-traumatic lower extremity amputations. Therefore, it is essential to utilize effective antibiotics to treat these infections. The International Working Group on the Diabetic Foot (IWGDF) and Infectious Diseases Society of America (IDSA) published updated guidelines in 2023, advising that empiric coverage for Pseudomonas aeruginosa is not necessary in Western countries and temperate climates. A prior systematic review on the epidemiology of P. aeruginosa in DFIs found a global prevalence of 16.6%, with the lowest prevalence of 11.1% being in Western countries. A review of patients at our institution, Cone Health, with toe and/or foot amputation(s), supported these findings with only 1.7% of cultures identifying P. aeruginosa. The most isolated pathogens were Staphylococcus aureus and coagulase-negative Staphylococcus species. The lower extremity wound order set at Cone Health was modified, removing empiric P. aeruginosa coverage due to its low incidence. The purpose of this study is to evaluate prescriber compliance with the updated order set and assess microbiological concordance between prescribed empiric therapy and cultured pathogens following the modifications.

Methods: This was an IRB approved, determined exempt, retrospective cohort analysis of individuals with diabetic foot infections at a single health system encompassing four community hospitals. The revised order set went live in February 2025. The review spanned a pre-intervention cohort from June to December 2024 and a post-intervention cohort from June to November 2025. Adults aged 18 years or older with confirmed DFI with or without osteomyelitis were included in this study. Those individuals admitted to the intensive care unit or with the presence of chronic foot ulceration were excluded. Infection-related information collected included wound classification, utilization of order set, inpatient antibiotics utilized, duration of antibiotics, type of amputation, culture results, pathology results and discharge antibiotics. The primary outcome of this study is adherence to order set recommendations, defined as aligning with the antibiotic recommendations per infection severity. Secondary outcomes include proportion of patients with microbiological match to empiric antibiotics, 30-day mortality rate and 30-day readmission rate.

Results: The post-intervention cohort demonstrated a modest increase in adherence to lower extremity wound order set recommendations compared to the pre-intervention cohort (34% vs 30%, p=0.55). Among patients with available culture data, all 17 individuals in the pre-intervention cohort received empiric antibiotics concordant with culture results compared to 26 of 30 patients (87%) in the post-cohort (p=0.075). Streptococcus species were the most commonly isolated gram-positive organisms in both cohorts (10 cases in the pre-cohort and 11 in the post-cohort). There was a higher prevalence of Proteus mirabilis and Enterobacter cloacae in the post-cohort, but these organisms demonstrated minimal resistance to penicillins and cephalosporins. The use of vancomycin and cefepime decreased from the pre- to post-intervention period, while utilization of linezolid and ampicillin/sulbactam increased.

Conclusion: The revised lower extremity wound order set was associated with a numerically higher rate of adherence compared to the prior version, with approximately half of providers in each cohort utilizing the order set. Empiric antibiotics demonstrated microbiological match in most cases. The organisms cultured in this study align with those typically observed in DFIs in the United States. The updated order set represents an advancement in antimicrobial stewardship in DFIs through the inclusion of preferred alternatives. Limitations of this study include variability in obtainment of pathology and cultures between providers as well as a small sample size. Future directions include reinforcing appropriate utilization of the DFI order set and evaluating discharge antibiotic therapy to assess the potential benefit of creating standardized recommendations.
Moderators
TO
Presenters
avatar for Katie Hindman

Katie Hindman

PGY1 Acute Care Pharmacy Resident
I am a PGY1 Acute Care Pharmacy Resident at Moses Cone Hospital in Greensboro, NC. I went to the University of South Carolina College of Pharmacy in Columbia, SC. I am excited to be staying at Cone Health to complete a PGY2 Infectious Diseases Pharmacy Residency next year!
Evaluators
TB
Friday May 1, 2026 10:40am - 11:00am EDT
Athena G
  Internal Medicine (IM), Cone Health
  • global Y

11:00am EDT

Evaluating Vancomycin AUC Monitoring in Adult Cystic Fibrosis Patients
Friday May 1, 2026 11:00am - 11:20am EDT
Athena D
Title 
Evaluating Vancomycin AUC Monitoring in Adult Cystic Fibrosis Patients 
 
Authors 
Taylor J. Merritt, Carrie Tilton Callahan, Kelly Soyeong Ko, Cynthia Shin-Yee Tsai, Heidi King Berman, Nicole L. Metzger  
 
Practice Site 
Emory University Hospital 
 
Objective  
Audience members will be able to evaluate the impact of AUC-based vancomycin monitoring on therapeutic target attainment and safety outcomes compared with traditional trough-based monitoring in adult patients with cystic fibrosis (CF)  
 
Background  
Area under the curve (AUC)–based vancomycin monitoring is recommended to improve efficacy and reduce nephrotoxicity. However, evidence supporting its use in adult people with cystic fibrosis (PwCF) remains limited.  
 
Methods  
This single-center, retrospective observational study included hospitalized adults with CF who received intravenous vancomycin and at least one appropriately drawn vancomycin level. Patients were excluded if they were pediatric, pregnant, incarcerated, had unstable renal function, or did not have vancomycin for > 48 hours. Encounters were grouped based on strategy: AUC or trough-based monitoring. Therapeutic targets were defined as: AUC of 400–600 mg·hr/L or trough of 15–20 mg/dL. Primary outcome was the proportion of encounters achieving therapeutic targets at first appropriate level. Secondary outcomes included time to therapeutic target attainment, number of regimen adjustments, length of hospital stay, and incidence of acute kidney injury. An exploratory analysis was conducted by reclassifying patients in the trough-based group who met institutional AUC-dosing criteria and assessing whether therapeutic targets would have been achieved when using an institutional AUC calculator.   
 
Results  
A total of 43 encounters representing 27 patients met inclusion criteria, with 16 encounters in the AUC-based group and 27 in the trough-based group. Therapeutic exposure targets at first level draw were achieved in 37.5% of AUC-monitored encounters compared to 14.8% of trough-monitored (p-value 0.14). Mean time to therapeutic target attainment was similar between groups, and no cases of acute kidney injury occurred in the AUC group compared to 7.4% in the trough-based group. Length of hospital stay and number of vancomycin levels collected were comparable between strategies. In the exploratory analysis, patients regrouped from trough to AUC demonstrated 48.3% therapeutic targets at initial draw compared to 0% in the trough-based group. 
 
Conclusions  
AUC-based vancomycin monitoring did not demonstrate a statistically significant improvement over trough-based monitoring in adults with cystic fibrosis; however, a trend toward improved therapeutic target attainment and no increase in nephrotoxicity was observed. These findings support consideration of AUC-based monitoring in this population and add to the limited data available for adult patients with cystic fibrosis. 
 
Self-Assessment Question 
Which statement best reflects the findings from this study?  
A) AUC-based monitoring significantly reduced AKI in PwCF   
B) AUC-based monitoring significantly improved target attainment   
C) Trough-based monitoring resulted in fewer regimen changes   
D) AUC-based monitoring demonstrated a trend toward improved target attainment without increasing AKI 
 
 
Contact Email 
[email protected] 

Moderators
avatar for Jessica Ringler
Presenters
avatar for Taylor Merritt

Taylor Merritt

PGY2 Internal Medicine Pharmacy Resident, Emory University Hospital
Dr. Taylor Merritt is from West Green, Georgia. She received her Bachelor of Science in Pharmaceutical Sciences and Doctor of Pharmacy degrees from Mercer University College of Pharmacy in Atlanta, Georgia. She is currently a PGY2 Internal Medicine Pharmacy Resident at Emory University... Read More →
Evaluators
avatar for Carrie Callahan

Carrie Callahan

Internal Medicine (IM) Specialist, PGY2 IM RPD, Emory University Hospital


Friday May 1, 2026 11:00am - 11:20am EDT
Athena D
  Internal Medicine (IM), Emory University Hospital
  • global Y

11:00am EDT

Impact of a Pharmacist-Led IV Iron Referral Pathway on Outpatient Referrals and IV Iron Administration - Vanna Labi
Friday May 1, 2026 11:00am - 11:20am EDT
Athena H
Background: Intravenous (IV) iron is an effective therapy for iron deficiency anemia, and growing evidence supports outpatient administration when clinically appropriate. Despite this, hospitalized patients frequently receive IV iron without a standardized process to ensure therapy completion after discharge. To address this gap, the adult iron replacement order set was updated to better facilitate ambulatory infusion referrals and incorporate a pharmacist consult. The consult prompts inpatient clinical pharmacists to review indication for IV iron with the ordering provider and determine whether remaining doses can be safely administered in the outpatient setting or if additional inpatient doses are medically necessary. The purpose of this study was to evaluate the impact of these order set changes on outpatient IV iron referral rates. 

Methods: This multi-center, IRB-reviewed determined exempt, retrospective cohort study evaluated adult patients receiving IV iron across four Cone Health hospitals and affiliated outpatient infusion centers. Patients with IV iron orders placed through the inpatient infusion order set during the study period were included. The primary outcome was the proportion of hospitalized patients receiving IV iron who were referred for outpatient infusion. Chi-square test was utilized to compare pre-intervention (September 17, 2024–May 12, 2025) and post-intervention (May 13, 2025–October 31, 2025) cohorts for the primary outcome. Secondary outcomes included the proportion of referred patients who received at least one outpatient IV iron dose, the proportion who completed their planned outpatient IV iron treatment course, median time from discharge to first outpatient IV iron administration, median time from discharge to first outreach for infusion scheduling, and reasons for incomplete outpatient IV iron treatment among referred patients. Descriptive statistics were used to summarize baseline characteristics. 

Results: Data on 201 patients were collected from both the pre- and postimplementation phases. During the pre-intervention period, 1,430 hospitalized patients received inpatient IV iron, with 36 patients (2.5%) referred for outpatient infusion. In the post-intervention period, 1,131 hospitalized patients received inpatient IV iron, and 168 patients (14.6%) were referred for outpatient infusion (p < 0.001).  Among referred patients, 31 of 36 patients (86.1%) in the pre-intervention group and 99 of 165 patients (60.0%) in the post-intervention group received at least one outpatient IV iron dose (p = 0.0029). Overall, 24 of 36 patients (66.7%) in the pre-intervention group and 88 of 165 patients (53.3%) in the post-intervention group completed their planned IV iron treatment course (p = 0.1445). Median time from hospital discharge to first outreach for infusion scheduling was 4 days (range 0–81) in the pre-intervention group and 3 days (range 0–30) in the post-intervention group. Median time from discharge to first outpatient IV iron administration was 13 days (range 5–91) in the pre-intervention group and 11 days (range 8–18) in the post-intervention group. The most frequently identified barriers to treatment completion were no-shows, inability to contact patients, rehospitalization, patient-directed delays, and documentation gaps. 

Conclusions: Implementation of an updated IV iron order set incorporating pharmacist review significantly increased referrals for outpatient IV iron therapy. Standardizing referral workflows at hospital discharge may improve continuity of care, support timely outpatient iron repletion, and optimize utilization of inpatient and ambulatory infusion resources.


Moderators
TC
Presenters
avatar for Vanna Labi

Vanna Labi

PGY1 Acute Care Pharmacy Resident, Cone Health - Moses H. Cone Memorial Hospital
Evaluators
avatar for Yona Roberts

Yona Roberts

RPD/Clinical Pharmacy Manager, WSGA1Wellstar Cobb HospitalPGY1
Yona Roberts earned a Doctor of Pharmacy degree from Florida Agricultural and Mechanical University in Tallahassee, Florida.  She went on to complete a Pharmacy Practice Residency through Mercer University at DeKalb Medical Center in Atlanta, Georgia.  After completion of her residency... Read More →
Friday May 1, 2026 11:00am - 11:20am EDT
Athena H
  Internal Medicine (IM), Cone Health
  • global Y

11:00am EDT

Impact of Midodrine on Optimization of Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction
Friday May 1, 2026 11:00am - 11:20am EDT
Athena C
Title: Impact of Midodrine on Optimization of Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction
Authors: Isabelle Perling, Jessica Starr, Nathan Pinner, Alyssa Osmonson, Kenda Germain
Objective: Discuss whether the addition of midodrine in patients with heart failure with reduced ejection fraction (HFrEF) facilitates optimization of Step 1 guideline-directed medical therapy (GDMT)
Self-Assessment Question: True or false, the addition of midodrine for HFrEF patients led to optimization of GDMT compared to those not started on midodrine.
Background: Heart failure is a complex syndrome that results from impairment of ventricular filling or blood ejection from the heart. It is classified by ejection fraction with the most common types being heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction.
Guideline-directed medical therapy (GDMT) for HFrEF includes four step 1 agents: renin-angiotensin system inhibition with an angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. These treatments prolong patient life, improve symptoms, and reduce hospitalizations for HFrEF patients. Due to the notable blood pressure lowering effects of many of these agents, some patients cannot tolerate full GDMT.
Midodrine is a peripheral alpha-1 agonist that increases arterial and venous tone resulting in increased BP. It is FDA approved for symptomatic orthostatic hypotension but has been used off-label for vasopressor weaning in the intensive care unit and hemodialysis associated hypotension. Because combining multiple agents of GDMT can lower BP, some clinicians are beginning to use midodrine to counteract hypotension and ensure full optimization of GDMT.
Methods: This is a single center, IRB approved, retrospective chart review in patients with HFrEF and at least one Step 1 GDMT agent(s) on their home medication list. Patients with ≥3 normotensive blood pressure readings, contraindications to GDMT, mixed heart failure, end stage kidney disease, liver failure, and addition of midodrine for vasopressor de-escalation or no prescription fill data post-discharge were excluded. The primary endpoint was optimization of Step 1 GDMT, including addition of further agents or dose increases in current. Secondary outcomes include addition of GDMT, dose increase in current GDMT, reduction of GDMT, dose decreases in current GDMT, 30-day re-admission, mortality within a year, ability to come off midodrine, and improvement in ejection fraction.
Results: 28 patients were analyzed, 14 on midodrine and 14 without midodrine. There was no difference in optimization of Step 1 GDMT between the midodrine and matched control group. 3/14 patients in the midodrine group were optimized on step 1 GDMT compared to 6/14 in the control group (p=0.225). There was a meaningful difference in mortality within a year between the midodrine and control groups, 5/14 and 1/14, respectively (p=0.065).
Conclusion: Midodrine did not result in a difference in optimization of GDMT. Mortality was higher in the midodrine group, emphasizing the need for further studies evaluating the safety of the medication in HFrEF patients.
Moderators
BW
Presenters
IP

Isabelle Perling

PGY2 Internal Medicine Pharmacy Resident, Baptist Health Princeton Hospital
Isabelle (Izzy) Perling, PharmD, is a PGY2 Internal Medicine Pharmacy Resident from Atlanta, Georgia. She completed her undergraduate courses at Auburn University before receiving her PharmD from the University of Georgia College of Pharmacy. Izzy completed PGY1 at Baptist Health... Read More →
Evaluators
avatar for Devon Burhoe
Friday May 1, 2026 11:00am - 11:20am EDT
Athena C
  Internal Medicine (IM), Baptist Health Princeton Hospital
  • global Y

11:20am EDT

Medication-induced falls in hospitalized patients: assessing the impact of anticholinergic drugs and the predictability of fall risk scores - William W. Feese
Friday May 1, 2026 11:20am - 11:40am EDT
Athena H
Introduction:    
Some of the most prescribed medications in the elderly population have potent anticholinergic properties, which are associated with potentially harmful side effects, such as an increased risk of falls. In addition, many elderly patients are on potentially inappropriate medications as defined by the Beers criteria, many of which can also increase fall risk. Pharmacists can play a pivotal role in preventing inpatient falls by proactively identifying patients taking potentially inappropriate medications and making recommendations related to de-prescribing or medication optimization. The objective of this study is to investigate if a causal relationship exists between inpatient falls and medication usage. 
Methods:  
This is a retrospective case-controlled study of adult patients aged 65 years or older admitted to The University of Tennessee Medical Center from January 2023 to May 2025. Patients were separated into two groups: the fall group, which included patients aged 65 years or older who had experienced an inpatient fall (as identified by ICD-10 codes for inpatient falls), and the control group, which included patients aged 65 years or older who had not experienced an inpatient fall. Patients were excluded if they were under 65 years old. The Anticholinergic Burden Score and the Beers Criteria scoring systems were utilized to assess the total number of potentially inappropriate medications the patients were taking at admission, during their hospital stay, and at discharge. The primary outcome is the median score on each scoring system at each time point: admission, during their hospital stay, and on discharge. Secondary outcomes are length of stay and discharge location. 
Results: 
A total of 310 participants met the inclusion criteria. Baseline characteristics were similar between groups except for a higher prevalence of atrial fibrillation in the no-fall group (P = 0.004). Both measures of potentially inappropriate medication exposure were significantly higher in patients who experienced a fall. Median Anticholinergic Burden scores were 4 vs 2 (P < 0.0001), and median Beers Criteria scores were 7 vs 5 (P < 0.0001) in the fall and no-fall groups, respectively. Despite no difference in admissions scores, the change in both metrics from admission to maximum inpatient values were significantly greater in the fall group (P < 0.0001). Patients who fell had a longer median length of stay (8 vs 4 days, P < 0.0001) and were more frequently discharged to skilled nursing facilities (P < 0.0001). A post-hoc analysis was conducted regarding past medical history for atrial fibrillation and Parkinson's disease, as they were significant or marginally non-significant, respectively. Each 1-point increase in Anticholinergic Burden Score increased fall risk by 26.9%, and each 1-point increase in Beers Criteria Score increased fall risk by 14.3% among patients with atrial fibrillation or Parkinson's disease. 
Conclusion: 
Patients who experienced an inpatient fall had significantly higher maximum Anticholinergic Burden and Beers Criteria scores than those who did not fall. Falls were also associated with longer hospital stays and a greater likelihood of discharge to a skilled nursing facility. Medication risk scores increased from admission through the time of the fall, suggesting an opportunity to improve inpatient medication optimization to prevent falls. Future research should evaluate high-risk medication combinations and dose-related effects within the Anticholinergic Burden and Beers Criteria to better guide prescribing for high-risk hospitalized patients. 

Moderators
TC
Presenters
avatar for William Feese

William Feese

PGY-2 Internal Medicine Pharmacy Resident, University of Tennessee Medical Center
Dr. Feese was born and raised in Lexington, Kentucky. He completed his Bachelor of Science in Pharmaceutical Sciences with an emphasis in Health Humanities from the esteemed St. Louis College of Pharmacy and his Doctor of Pharmacy from the University of Health Sciences and Pharmacy... Read More →
Evaluators
avatar for Yona Roberts

Yona Roberts

RPD/Clinical Pharmacy Manager, WSGA1Wellstar Cobb HospitalPGY1
Yona Roberts earned a Doctor of Pharmacy degree from Florida Agricultural and Mechanical University in Tallahassee, Florida.  She went on to complete a Pharmacy Practice Residency through Mercer University at DeKalb Medical Center in Atlanta, Georgia.  After completion of her residency... Read More →
Friday May 1, 2026 11:20am - 11:40am EDT
Athena H
  Internal Medicine (IM), University of Tennessee Medical Center
  • global Y

11:40am EDT

Comparative Evaluation of IV Push Versus IV Infusion Administration of Levetiracetam
Friday May 1, 2026 11:40am - 12:00pm EDT
Athena G
Comparative Evaluation of IV Push Versus IV Infusion Administration of Levetiracetam 
Tavin Cook, Ashley Crisler, T.J. Henderson, Aayush Patel 
Piedmont Columbus Regional Midtown, Columbus GA

Background:
Levetiracetam is commonly administered as an IV infusion; however, IV push (IVP) administration has the potential to improve medication turnaround times, reduce nursing workload, and lower medication preparation costs without compromising safety. In January 2026, Piedmont Columbus Regional implemented IVP levetiracetam hospital wide. The objective of this study is to compare the timeliness of administration and cost difference associated with IVP levetiracetam versus IV infusion levetiracetam. 

Methods:
This study was a single-center, Institutional Review Board (IRB)–approved, retrospective chart review. The overall study timeframe spanned from October 13, 2025, to March 13, 2026. The pre-implementation period was October 13, 2025, to January 12, 2026, and the post-implementation period was January 14, 2026, to March 13, 2026. The study included adult patients aged 18 years or older who received intravenous levetiracetam at doses of less than 2 grams.  An EHR Slicer/Dicer data collection tool was used to collect points of time of order entry, order verification, and administration of medication. Cost analyses were conducted by integrating direct drug cost. The primary objective is to assess the difference in time from order verification to administration of once dose levetiracetam pre and post implementation. Secondary objectives include direct drug cost, time-critical medication compliance, and adverse drug reactions. Statistical analysis for the primary outcome used Mann-Whitney-U, secondary outcome descriptive analysis and chi-square testing. 

Results:
IV push levetiracetam demonstrated a numerically faster time to administration compared to IV infusion (19.7 vs 23.9 minutes), though this difference was not statistically significant (p=0.41). Time-critical medication compliance was significantly higher with IV push (85.7% vs 81.8%, p<0.001), and no adverse drug reactions were reported in either group. Additionally, IV push was associated with substantially lower direct drug costs, translating to significant projected annual savings.

Conclusions:
IV push levetiracetam is a cost-effective alternative to IV infusion that improves time-critical medication compliance while maintaining a comparable safety profile. Although a faster administration trend was observed, it did not reach statistical significance. Overall, IV push represents a practical and efficient strategy for levetiracetam administration within institutional practice.

Contact:
[email protected]   

Moderators
TO
Presenters
avatar for Tavin Cook
Evaluators
TB
Friday May 1, 2026 11:40am - 12:00pm EDT
Athena G
  Internal Medicine (IM), Piedmont Columbus Regional Midtown
  • global Y

11:40am EDT

Dalbavancin versus oral antibiotics for Staphylococcus aureus bone and joint infections
Friday May 1, 2026 11:40am - 12:00pm EDT
Athena J
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. 


Moderators
avatar for Jeremy Walley
Presenters
avatar for Mackenzie Pearsall

Mackenzie Pearsall

PGY1 Pharmacy Resident, Atrium Health Wake Forest Baptist
Evaluators
avatar for Jessica Sterchi

Jessica Sterchi

Clinical Pharmacy Supervisor and Acute Care PGY1 RPD, BMHT1Blount Memorial HospitalPGY1
Friday May 1, 2026 11:40am - 12:00pm EDT
Athena J
  Internal Medicine (IM), Wake Forest Baptist
  • global Y

11:40am EDT

Evaluation of Electronic Health Record Alerts for Heparin Use After Direct Oral Anticoagulant Exposure
Friday May 1, 2026 11:40am - 12:00pm EDT
Athena D
Background: Anticoagulation therapy in hospitalized patients is inherently high-risk with complex dosing requirements and significant potential for drug interactions. Heparin is an anticoagulant that utilizes laboratory monitoring to target therapeutic concentrations, but accuracy of anti-Xa levels can be falsely elevated due to recent direct oral anticoagulant (DOAC) exposure. Our practice advisories (OPAs) are utilized within the electronic health record (EHR) to improve clinical decision-making and advance patient safety. The study site employs OPA alerts to identify elevated anti-Xa levels in patients who may have had recent exposure to a DOAC with the goal of helping practitioners decide if a reagent that removes DOAC effect on anti-Xa (DOAC-StopTM) should be utilized.  The objective of this study was to analyze the impact of an OPA for elevated anti-Xa levels in patients receiving heparin infusions with recent potential or known DOAC exposure, focusing on clinical appropriateness of DOAC-StopTM utilization and safety outcomes. 
Methods: This single center, retrospective cohort study analyzed patients with an elevated anti-Xa OPA alert(s) between January 1st and April 3rd, 2024 focusing on clinical appropriateness and safety outcomes. OPAs alerted for patients who were on a heparin infusion, had an elevated anti-Xa ≥ 1, and were within three days of admission or had documented receipt of a DOAC within the previous five days. Exclusion criteria included pregnancy, incarceration, switching between heparin protocols during the admission, and administration of enoxaparin within 24 hours of the elevated anti-Xa. The primary outcome assessed the appropriateness of subsequent actions in response to the OPA. Appropriateness was defined based on a treatment flowchart developed for study. Secondary outcomes included incidence of bleeding within 24 and 48 hours of the alert(s) per the International Society on Thrombosis and Haemostasias (ISTH) bleeding criteria and a subgroup analysis of DOAC-StopTM utilization by level of care and nursing shift. 
Results: A total of 100 patients were included in the final analysis. At baseline, 46% of patients were receiving apixaban, 6% rivaroxaban, and 48% were not receiving any anticoagulant within the 72 hours prior to heparin initiation. Clinical use of DOAC-StopTM following the first OPA was deemed appropriate for 92% of initial advisories and inappropriate for 8%. Inappropriate use, according to the study-developed flowchart, included administering DOAC-Stop™ to patients without prior DOAC exposure and omitting it in high-risk patients with prior exposure. There was no statistically significant difference between appropriate clinical use based on time of shift (p = 0.426) or by level of care (p = 0.119). Bleeding events were mostly attributable to clinically relevant non-major bleeding or major bleeding defined as a hemoglobin decrease of 2 mg/dL or more that required no clinical intervention. These events occurred within 0-24 hours in 11% of patients and within 0-48 hours in 18% of patients.  
Conclusions: While the true effect of this OPA is difficult to discern given lack of a control group, the high level of appropriate advisory response indicates that it was successful in identifying potential candidates for DOAC-StopTM and ensuring that high-risk patients received adequate anticoagulation evaluation. Practice advisories and protocols do not account for every scenario, and clinical judgement must be utilized to determine candidacy for DOAC-StopTM. 


Moderators
avatar for Jessica Ringler
Presenters
avatar for Kaitlyn Wallace
Evaluators
avatar for Carrie Callahan

Carrie Callahan

Internal Medicine (IM) Specialist, PGY2 IM RPD, Emory University Hospital


Friday May 1, 2026 11:40am - 12:00pm EDT
Athena D
  Internal Medicine (IM), Grady Memorial Hospital
  • global Y
 

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