2026 Southeastern Residency Conference

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

Title: Evaluation of Early Onset Severe Treatment-related Adverse Events for Fluoropyrimidine-based Chemotherapy
Authors: Alexandria Rakestraw, Alex Balkcom, Rodna Larson
Background:
Fluoropyrimidines such as 5-fluorouracil (5-FU) and capecitabine are commonly used in the treatment of solid tumors. Fluoropyrimidines work by inhibiting thymidylate synthase and incorporating the metabolites into DNA synthesis, disrupting the creation of cancerous cells.
The toxicities of fluoropyrimidines are typically seen within the first few cycles of treatment. Toxicities can occur due to the mechanism of action of fluoropyrimidines or can occur due to genetic mutations but can be enhanced by genetic mutations. Fluoropyrimidines are metabolized by dihydropyrimidine dehydrogenase. Dose reductions are based on variants to avoid potential accumulation and therefore potential toxicities.
This retrospective chart review was designed to identify CTCAE grade 3-5 toxicities in patients receiving fluoropyrimidine-based treatments, explain dose modifications secondary to genotypic variation, and understand the current practice of genotype testing prior to receiving these chemotherapeutic agents.
Methods:
This single-center, retrospective, observational chart-review was conducted at our institution from January 1, 2023, to February [RA1] 1, 2026. Adults >18 were eligible to be included in this study if they received 5-FU or capecitabine for any solid tumor and if the first dose of either medication was given within the study period. Patients were excluded from the study if the patient was being treated in a clinical trial.
The primary objective of the study was to determine the incidence and onset of grade 3-5 fluoropyrimidine-related toxicity within the first three cycles of treatment in correlation with DPYD genotype status. The specified narrowed toxicities include diarrhea, mucositis, cardiotoxicity, palmar plantar erythrodysesthesia, and pancytopenia (thrombocytopenia and neutropenia). Secondary endpoints included identification of genotypic variants, retrospective dose adjustments, time to death, and genotype testing turnaround times.
Results:
Among 85 patients treated with fluoropyrimidine-based chemotherapy (5-FU, n=51; capecitabine, n=34), DPYD genetic testing rates were low overall, yet patients tested prior to treatment initiation experienced a 59% reduction in grade 3+ toxicity events compared to untested patients (10.0% vs 24.6%, RR=0.41).
Conclusions: 
These data suggest that pre-treatment DPYD screening may reduce severe fluoropyrimidine-related toxicity, though the difference did not reach statistical significance given the limited sample size. Testing is available as a blood draw that has an average 9-day turnaround time.
  

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

Inpatient Medication Use Evaluation of Chemotherapy-Induced Febrile Neutropenia

Background/Objective: Neutropenic fever occurs in about one percent of chemotherapy patients and requires prompt empiric antipseudomonal β‑lactam therapy. The Infectious Diseases Society of America (IDSA) guidelines recommend monotherapy with cefepime or piperacillin-tazobactam, as first-line empiric therapy. They do not recommend routine antiMethicillin-resistant Staphylococcus aureus (MRSA) coverage unless prior history of MRSA infection or differential diagnosis warrants coverage. In addition, the 2024 Working Group on Infections in Hematology and Oncology (AGIHO) guidelines now recommend discontinuing empiric antibiotic therapy after 72 hours of apyrexia regardless of absolute neutrophil count (ANC). The purpose of this study is to evaluate the appropriateness of antibiotic prescribing patterns for chemotherapy-induced febrile neutropenia (CIFN). The result will help develop a future project involving antimicrobial stewardship interventions with the goal of increasing guideline adherence.

Methods: This was a single-center retrospective cohort study. Patients at least 18 years of age admitted for CIFN between July 2023 to June 2025 at Atrium Health Navicent were identified through International Classification of Disease diagnosis codes. To be included in the study, patients were required to have ANC was less than 500 cells/µL following chemotherapy with a concurrent fever or a MASCC score less than 21 regardless of ANC and received intravenous antibiotics for greater than 72 hours. Patients who had nonchemotherapy induced neutropenic fever or documented allergies preventing guidelineadherent therapy were excluded from the study. The primary outcome was composite of appropriate empiric antibiotic therapy initiation and appropriate de-escalation of therapy after 72 hours. The secondary outcomes included appropriate empiric antibiotic initiation, appropriate de-escalation of empiric therapy at 72 hours, length of antibiotic therapy, microbiological culture results matched with appropriate de-escalation, mortality rate during hospitalization, and adverse events compared to appropriate therapy.

Results: A total of 95 patients were screened, and 42 were included in the study. The mean age was 56.2 years (IQR 49-64.5) with 50% being male. Antipseudomonal β-lactams were the most common empiric agents used with cefepime 71.4% (30/42) and piperacillintazobactam 23.8% (10/42) of cases, followed by vancomycin for MRSA coverage in 83.3% (35/42) of cases, and meropenem for Extended-spectrum beta-lactamase (ESBL) coverage in 2.4% (1/42) of cases. The primary composite outcome of appropriate empiric initiation and appropriate re-evaluation at 72 hours occurred in 19% of patients. The secondary outcomes of appropriate empiric initiation occurred in 31% of patients, and the rate of appropriate antimicrobial evaluation at 72 hours was 57.1% of patients. Culture-matched antibiotics were performed in 71.4% of patients. In-hospital mortality rate was 7.1% and adverse events rate was 2.4% in patients.

Conclusions: Most patients with chemotherapy‑induced febrile neutropenia received inappropriate empiric antibiotic initiation and inappropriate duration of antimicrobials per guideline recommendations. This quality improvement project identified several practice gaps and serves as a baseline for future projects involving antimicrobial stewardship at Atrium Health Navicent.

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

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 [KN1]included

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

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

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

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

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

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

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

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

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

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

Authors: Makenzie Boyd & Barbie Gleaton

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

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

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

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

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

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