2026 Southeastern Residency Conference

Authors: Tsuraya Iswanto, Mariam Saba, Victoria Phan

Background: Resmetirom, a selective agonist of THR-β in the liver, received FDA accelerated approval in March 2024 for treatment of metabolic dysfunction-associated steatohepatitis (MASH) with stage F2-F3 fibrosis. Patients prescribed on resmetirom often have comorbidities of hypertension, dyslipidemia, and diabetes. As a limited distribution drug, resmetirom is dispensed only through select specialty pharmacies. Due to its recent approval, adherence and side effect data are limited, creating an opportunity for retrospective data analysis to identify therapy-related barriers and guide interventions.

Methods: This will be a retrospective data analysis (from March 2025 to April 2026) involving patients who were prescribed with resmetirom, have a diagnosis of MASH, and had an initial fill and refills from a community-based specialty pharmacy. Patients will be included in this study if they are prescribed resmetirom and have a documented prescription refill record for at least 5 months. Patients will be excluded from the study if they have been on resmetirom for less than 6 months. Adherence will be analyzed using Proportion of Days Covered (PDC) scores. Patients must have had at least 6 total fills (or 180 days) of therapy for PDC scores to be calculated. The pharmacy dispensing system data with dates of the initial fill and refills will be used for PDC scores. PDC scores will be categorized into two adherence groups: PDC scores will be categorized into two adherence groups: > 98% and < 98%. Therapy outcomes will be assessed by self-reported health status shared by the patient during 6-month therapy reassessments. From pharmacy reassessments calls, the following data will be collected: 1. Data including patient reported side effects 2. Perceived effectiveness of resmetirom in managing MASH treatment 3. Missed doses 4. Challenges while taking resmetirom related to drug therapy • For drug interactions, the pharmacist will identify patients who are on medications that require pharmacist intervention due to major interactions with resmetirom (Statins, CYP2C8 inhibitors, or other hepatotoxic medications).

Results (preliminary results): Overall adherence was high, with a mean PDC of 98.17% and 65.3% of patients classified as highly adherent (≥98%). Patients with ≥98% adherence demonstrated a higher proportion of positive perception compared to those with lower adherence. Adherence showed a non-significant trend towards improved positive perception (OR = 1.54, p = 0.47) and reduced side effects (OR = 0.52, p = 1.00). Confidence intervals were wide, indicating high uncertainty. No statistically significant associations were observed.

Conclusions (reached to date): Adherence to resmetirom therapy was high, and patient-perceived effectiveness was positive. Higher adherence (≥98%) showed trends toward more positive perception (OR 1.54) and fewer side effects (OR 0.52), however were not statistically significant. Limited variability and small sample size likely reduced power to detect associations. These findings can help specialty pharmacists identify strategies that can be implemented to improve therapy outcomes by identifying potential barriers to continuing therapy.

E-mail of resident: [email protected]

Authors: Alexa Ruzicka, Magen Check, Austin Weiss, Tamara Downing, Ashlee Baucom 

Background:  
Diabetic ketoacidosis (DKA) is a serious complication of insulin deficiency and a leading cause of hospitalization and mortality among children with type 1 diabetes mellitus (T1DM). Intravenous fluid resuscitation is a critical component of DKA therapy. However, fluid therapy in children carries unique risks, most notably cerebral edema. To mitigate these risks, current pediatric guidelines recommend gradual correction of hyperglycemia and acidosis using continuous insulin infusion and staged fluid replacement. Many institutions utilize a two-bag method, which allows for rapid titration of dextrose concentration while maintaining a continuous insulin infusion and consistent electrolyte delivery. The composition of the standard DKA bags used in the two-bag protocol was changed at the study institution in June 2024. The purpose of this study was to compare clinical outcomes before and after the implementation of the revised two-bag fluid composition for pediatric DKA.  

Methods: 
This study is an institutional review board approved, single center, retrospective cohort study. Pediatric patients (≤ 17 years of age) with a diagnosis of T1DM admitted to the PICU for management of DKA between June 1, 2023, and July 1, 2025, were eligible for inclusion. DKA was defined according to institutional and International Society for Pediatric and Adolescent Diabetes (ISPAD) criteria. Patients were excluded if custom IV fluid bags were utilized during DKA management. The primary endpoint was the time (in hours) from initiation of IV insulin infusion to transition to subcutaneous insulin therapy, which was a surrogate marker for DKA resolution. Secondary outcomes included time to DKA resolution, defined by biochemical markers including serum bicarbonate, anion gap closure, venous pH and beta-hydroxybutyrate. Additional secondary outcomes included PICU and total hospital length of stay, and incidence of cerebral edema, hypoglycemia and hyperchloremia. Mann-Whitney U tests were used to evaluate baseline characteristics, time to DKA resolution, and length of stay. Chi-squared tests were utilized to evaluate the incidence of treatment-related complications.  

Results: 
109 pediatric patients met inclusion criteria. There were 44 patients and 65 patients in the previous and current bag composition groups, respectively. Baseline characteristics were similar between groups. The median time to transition to subcutaneous insulin was shorter in the current bag composition group compared to the previous bag composition group (11.98 hours vs 13.75 hours, p = 0.174). There was no statistically significant difference in the biochemical endpoints of DKA resolution between groups.  
Rates of treatment-related complications were comparable between groups. The incidence of severe hypoglycemia (< 70 mg/dL) was low in both cohorts (2% vs 3%, p = 0.523), with moderate hypoglycemia occurring at a higher rate (< 100 mg/dL) (23% vs 37%, p = 0.117). Hyperchloremia occurred at a similar rate in both groups (82% vs 83%, p = 0.865). There were no statistically significant differences in cerebral edema (2% vs 6%, p = 0.342) or new-onset T1DM (36% vs 28%, p = 0.338). There were no significant differences observed in PICU length of stay (26.16 vs 27.32 hours, p = 0.91). However, the total hospital length of stay was longer in the current bag composition group (33.9 vs 35.6 hours, p = 0.03).

Conclusion: 
The modification of the two-bag IV fluid composition for pediatric DKA did not result in significant differences in time to DKA resolution, complication rates, or PICU length of stay. Hospital length of stay was longer in the current bag composition group.  

Contact email: [email protected]

Background: Staphylococcal scalded skin syndrome (SSSS) is a serious toxin-mediated dermatologic condition that primarily affects young children and is an important cause of pediatric hospitalization. This syndrome is caused by exfoliative toxins produced by Staphylococcus aureus, resulting in diffuse erythema, skin fragility, and superficial blistering with subsequent desquamation. Current management focuses on eradication of the toxin-producing organism with systemic antistaphylococcal antibiotics in conjunction with supportive care. Beta-lactam antibiotics with activity against methicillin-susceptible S. aureus, such as nafcillin, are considered first-line therapy. Clindamycin is frequently used as adjunctive therapy due to its ability to inhibit bacterial protein synthesis and suppress toxin production. However, the addition of clindamycin for antitoxin use in SSSS has remained controversial with conflicting findings in primary literature of whether it should be added to mainstay treatment. This study evaluates the association between adjunctive clindamycin use in combination with nafcillin and length of stay (LOS) in pediatric patients with SSSS at our institution. Methods: A single-center, institutional review committee (IRC)–approved retrospective analysis was conducted at Huntsville Hospital for Women and Children to evaluate nafcillin monotherapy compared to the combination of nafcillin and clindamycin in relation to LOS of patients admitted between January 1, 2019 and August 31, 2025. Pediatric patients ages one month to 18 years that received at least one dose of nafcillin and with an ICD-10 code L00 for SSSS were included in the analysis. Patients with alternate diagnoses, concomitant infections requiring broader-spectrum antibiotics, or transferred out of the facility due to needing a higher level of care were excluded. The primary outcome was hospital LOS between the two groups. Secondary outcomes included the utilization of adjunctive and supportive medications during hospitalization, specifically the use of scheduled pain medications, scheduled antipruritic medications, as-needed (PRN) pain medications, and PRN antipruritic medications. Continuous variables were summarized using means with standard deviations and medians with interquartile ranges (IQR). Categorical variables were reported as percentages. Analysis for statistical significance was computed using RStudio ®.Results: Eighty-five patients were included in the evaluation of the primary and secondary endpoints. 18 patients were treated with nafcillin monotherapy and 67 were treated with the combination of nafcillin and clindamycin. Mean LOS was 3.89 ± 1.78 days in the nafcillin group and 3.70 ± 1.66 days in the combination group, corresponding to a mean difference of −0.19 days (95% CI −1.10 to 0.69; p = 0.78). Median LOS was 3.5 days (IQR 3.0–4.8) for nafcillin monotherapy and 4.0 days (IQR 3.0–4.0) for combination therapy (Hodges–Lehmann shift 0 days; 95% CI −1 to 1; p = 0.78). No secondary outcomes were statistically significant after adjustment for multiple comparisons. Local microbiologic data demonstrated low clindamycin resistance among MSSA isolates (10%) and overall low prevalence of MRSA isolates (7.4%).Conclusion: The combination of nafcillin and clindamycin use was not associated with a statistically significant reduction in hospital LOS among pediatric patients with SSSS. These findings align with prior literature suggesting limited impact of clindamycin on hospitalization duration1, 2. Additionally, no statistically significant differences were observed in the secondary outcomes evaluating the utilization of scheduled or as-needed medications. Routine adjunctive clindamycin use for LOS reduction in pediatric SSSS is not supported by this data and should be considered within the context of institutional susceptibility patterns and antimicrobial stewardship principles.

Title: Comparison of Heart Rate and Blood Pressure Control Agents in Acute Aortic Dissection
Authors: Brianna Lu, Kathryn Harvell, Ginger Gamble
Background: Anti-impulse therapy is the cornerstone of acute aortic dissection management to prevent rupture or dissection extension and has been shown to decrease long-term aorta-related adverse events. The American Heart Association/American College of Cardiology and European Society of Cardiology recommend a goal heart rate (HR) between 60 and 80 beats per minute and a goal systolic blood pressure (SBP) less than 120 mmHg. Current guidelines recommend beta blockers as initial therapy to achieve goal HR and BP; however, this is muddled by the absence of guideline-directed hierarchies within each drug class and lack of clear criteria for when therapy should be modified.
Methods: This single-center, retrospective, observational analysis identified patients 18 years or older treated for acute aortic dissection at an academic medical center from January 1, 2021 to October 1, 2025 and received intravenous labetalol, esmolol, nitroprusside, nicardipine, clevidipine, diltiazem, or verapamil. The primary outcome was the percent of patients with treatment failure, defined as switching study drugs, death prior to operative intervention, or not at goal HR (less than or equal to 80 bpm) and SBP (less than 120 mmHg) at 3 hours.  Statistical analyses include Fisher’s Exact for categorical variables and Mann Whitney-U for continuous variables.
Results: A total of 56 patients met inclusion criteria, and 38 patients were included in the final analysis. Thirty (88%) patients who received esmolol and 3 (75%) patients who received labetalol failed treatment at 3 hours (p = 0.45). At 6 hours, 27 patients who received esmolol and 3 patients who received labetalol failed treatment (p > 0.99). The median time to switch agents was 4.67 hours versus 3.64 hours in the esmolol and labetalol groups (p = 0.69). There was a difference in median time to first goal HR for esmolol at 0.47 hours compared to 0 hours in the labetalol group (p = 0.02). In contrast, there was no difference in median time to first goal SBP or in the percent of HR or SBP readings at goal at either 6 hours or 24 hours. Four patients (11.7%) died in the esmolol group compared to none in the labetalol group. The median intensive care unit length of stay was 4.05 days and 7.55 days for the esmolol and labetalol groups, respectively. A subgroup analysis comparing patients who received esmolol only (n = 11) versus labetalol found no difference in treatment failure rates at 3 hours (p = 0.47) or 6 hours (p > 0.99).
Conclusion: This study suggests there is no difference in treatment failure rates between esmolol and labetalol used for the management of acute aortic dissection at this institution. Secondary outcomes suggest that there may be benefit in the implementation of protocols to assist with optimizing titration of study drugs to achieve goal HR and SBP in a timelier fashion. Additional studies may be warranted to evaluate other differences in clinical outcomes between esmolol and labetalol.
Contact Information: [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.

Impact of Daptomycin Weight-Based Dosing Strategies in Obese Patients with Staphylococcal and Enterococcal Infections
Coleton Waggoner, Emily Perez, David Laurent
Background: High-dose daptomycin (>8 mg/kg) is increasingly utilized for severe Staphylococcus aureus and Enterococcus infections. However, optimal weight-based dosing in obese patients remains undefined. Daptomycin exposure is nonlinear with weight, and consequently, obese patients may be at risk for excessive exposure and adverse outcomes when dosing by total body weight (TBW).

Methods: This multicenter retrospective cohort study evaluated hospitalized adult obese patients (BMI ≥30 kg/m²) treated with high-dose daptomycin at ECU Health from January 2022 to July 2025. Patients were categorized into TBW or ABW (adjusted body weight) cohorts as determined by infecting pathogen: 8-10 mg/kg ± 0.5 mg/kg for S. aureus or 10-12 mg/kg + 0.5 mg/kg for Enterococcus spp.

The primary outcome was a composite safety endpoint of serum creatinine kinase (CK) elevation (>600u/L), patient-reported myopathy, rhabdomyolysis, or early discontinuation of daptomycin. Secondary outcomes included individual components of the composite safety endpoints as well as efficacy endpoints including readmission at 90 days, mortality at 90 days, resistance development at 90 days, and daptomycin discontinuation due to lack of efficacy. Baseline characteristics and outcomes were compared between groups using chi-square or Fisher’s exact tests for categorical variables and Mann-Whitney U tests for continuous variables.

Results: A total of 101 patients were included (TBW n=40; ABW n=61). Several differences in baseline characteristics existed between groups; the ABW cohort was significantly older (60.8 vs 56.1 years; p=0.025), had a higher mean BMI (38.7 vs 36.1 kg/m2; p=0.041), and had a higher prevalence of concomitant statin use (45.9% vs 20.0%). The primary composite safety outcome occurred in 20.0% (n=8/40) of TBW vs 19.7% (n=12/61) of ABW patients (p=0.78). CK elevation occurred in 20.0% vs 16.4% (p=0.59), myopathy in 5.0% vs 4.9% (p=1.00), and rhabdomyolysis in 2.5% vs 0% (p=0.39) in TBW and ABW groups, respectively. Discontinuation due to safety concerns occurred in 15.0% vs 8.2% (p=0.34). Ninety-day mortality was 20.0% vs 16.4% (p=0.64). There were no significant differences in secondary outcomes.

Conclusions: In this cohort of obese patients receiving high-dose daptomycin, TBW and ABW based dosing strategies demonstrated similar rates of composite safety events, as well as exploratory efficacy outcomes.

Email: [email protected]

Title: Comparative Outcomes of Oral Beta-Lactams Versus Fluoroquinolones or Trimethoprim-Sulfamethoxazole for Step-Down Therapy in Enterobacterales Bacteremia Secondary to Urinary Tract Infections

Primary: Taylor Hewitt
Secondary: Jordyn Meredith, Joseph Crosby, Courtney Zeigler

Background: This single-center, retrospective, observational cohort study was conducted at St. Joseph’s/Candler Health System to assess treatment failure in patients with Enterobacterales bacteremia secondary to urinary tract infections (UTIs) who received oral step-down antibiotic therapy. The study included patients hospitalized between January 1, 2022, and August 1, 2025, identified using ICD-10 codes for bacteremia. Electronic medical records were reviewed to confirm infection from a urinary source, requiring matching positive urine and blood cultures for Escherichia coli, Klebsiella spp., or Proteus spp. Eligible patients were adults (≥18 years) who received parenteral antibiotics during admission, followed by oral step-down therapy with either a beta-lactam, fluoroquinolone (FQ), or trimethoprim-sulfamethoxazole (TMP-SMX). Exclusion criteria included polymicrobial bacteremia, absence of oral step-down therapy, discharge to hospice, or pregnancy. Patients were stratified into two groups: those who received oral beta-lactams versus those who received FQ or TMP-SMX. The primary outcome was treatment failure, defined as a recurrent positive urine or blood culture for the same organism within 60 days of the initial diagnosis. The secondary outcomes included duration of therapy (both parenteral and oral), and hospital length of stay. Descriptive statistics summarize baseline characteristics and outcomes. Continuous variables were analyzed using Student’s t-test, and categorical variables using chi-square tests or appropriate non-parametric alternatives. Analyses were performed using Microsoft Excel, with statistical significance defined as a two-sided p-value < 0.05.

Results: Thirty-eight patients were enrolled in this study, including 11 patients who received oral beta-lactams and 27 patients who received fluoroquinolones (FQ) or trimethoprim-sulfamethoxazole (TMP-SMX). The primary outcome of treatment failure occurred in 7 patients (64%) from the beta-lactam group and 1 patient (4%) from the FQ/TMP-SMX (p=0.00004). No significant difference was found between the two groups for secondary outcomes duration of therapy and hospital length of stay.

Conclusion: In this study assessing treatment failure in patients with Enterobacterales bacteremia secondary to urinary tract infections (UTIs) who received oral step-down antibiotic therapy, a higher percentage of patients experienced treatment failure in the beta-lactam group compared to the FQ/TMP-SMX group.  The secondary outcomes of length of hospital stay and duration of therapy were similar across both groups. Potential limitation factors include inability to assess adherence to antibiotic therapy outpatient and step-down to oral therapy occurring at different points within the hospital stay. Future studies should target a larger population with only in-patient stepdown therapy due to the traceability of patients receiving antibiotics.

Evaluating Provider Behavior Around Alternative Fluid Orders During the 2024 IV Fluid Shortage
Authors: Cady Thomas, Jennifer Peltz, Christopher Dennis
Practice site: ECU Health 
Contact: [email protected]


Background: In September 2024, Hurricane Helene hit the western part of North Carolina and caused damage to a Baxter manufacturing plant which produces multiple sterile IV fluid products. Most health systems across the US relied on this plant for at least a portion of their IV fluid needs. Damage to the plant led to a major IV fluid shortage across the country. ECU Health utilized a series of medication alternative alerts to provide guidance to providers that were ordering IV fluid products during the shortage. Providers were allowed to select from the approved alternative list or to cancel the orders. The list of alternatives established limits on the amount of fluid that could be ordered and the duration of the orders. After selecting an option from the alternative list, providers had the ability to deviate from the recommendations by modifying order details before signing the orders. The purpose of this study was to evaluate the effectiveness of the medication alternatives in guiding ordering practices and to identify patterns in provider behaviors surrounding use of the tools throughout ECU Health. To establish a baseline expectation for alternative performance during shortages, we referenced prior studies with comparable clinical decision support designs. Sandler et al. reported alternative acceptance in 4.8% of cases and order cancellation in 6.2%.1​​​​ When combined, 11.1% of provider actions resulted in a desired outcome (recommended use accepted or no use), a rate we define as non-deviation for the purposes of our analysis. Whether similar outcomes occur around alternative fluid orders in other health systems is unclear.

Methods: The health system’s Clarity database was queried to identify all instances of medication alternatives triggered for IV fluids that were on shortage between October 9, 2024 and January 13, 2025. To better understand provider behavior and clinical impact, alternatives were then grouped into episodes which serve as the primary unit of evaluation for this study. 15,774 IV fluid episodes were included for analysis. The primary objective was to compare the proportion of episode non-deviations at our institution with rates previously reported in the Sandler et al. study. Episodes resulting in orders with deviations were further categorized by waste production and time deviations. Episodes were also categorized by provider type, type of IV fluid ordered, source of the order, hospital location of order origin, and patient age. The rate of non-deviation in our cohort was compared with the rate reported by Sandler et al. using a Chi-square test of independence. Descriptive statistics were used to describe other data points collected.

Results: Among 15,774 episodes, the non-deviation rate was 86.3% in our cohort compared with 11.1% in the comparator study, representing an absolute difference of 75.2% (95% CI 74.3 –76.1). This difference was statistically significant (χ²(1) = 12,203.007, p < 0.001). Of the episodes that resulted in deviations, 181 episodes resulted in time deviations; 2,034 episodes resulted in waste deviations. It was estimated that 815 L of fluid was wasted because of order deviations.  

Conclusion: Deviation from recommended alternatives occurred less frequently in our study compared with a prior alternative order study, though direct comparison is limited by differences in clinical context.  While our study shows a statistically significant improvement, the vast majority of episodes indicate providers still choose to deviate from the alternative recommendations which resulted in substantial IV fluid wastage. By recognizing prescribing patterns in areas that were more impacted by order deviations during the IV fluid shortage, the institution can employ additional strategies to help further minimize orders that deviate from recommendations.  


1. Sandler M, Cavanaugh J, Walton T, Cavendish L, Shah K. Management of an i.v. fluid shortage through use of electronic medical record alerts. American journal of health-system pharmacy. 2020;77:546-551.

Background: Staphylococcus aureus is one of the most clinically significant bacterial pathogens and can cause a wide range of infections, from mild skin and soft tissue infections to invasive bloodstream infections with severe complications. The standard of care for methicillin-susceptible S. aureus (MSSA) bloodstream infections has been an antistaphylococcal penicillin or a first-generation cephalosporin, such as cefazolin (CZ). Recent literature has shown no efficacy difference between CZ and antistaphylococcal penicillins, but has shown that CZ may be associated with less side effects. This has led to CZ becoming the preferred agent for MSSA bacteremia at our institution. MSSA is also covered by most broad-spectrum β-lactams, including piperacillin-tazobactam (TZP), cefepime (FEP), ertapenem (ETP), and meropenem (MEM). These broad-spectrum agents are primarily used for their activity against Pseudomonas aeruginosa or pathogens at high risk for inducible AmpC production, such as Enterobacter cloacae or Klebsiella aerogenes. Of note, ETP lacks anti-pseudomonal coverage but is used for treatment of other resistant pathogens, such as extended-spectrum β-lactamase (ESBL) producing organisms. In cases of polymicrobial infections, these broad-spectrum β-lactams may be used as targeted therapy for MSSA in addition to the gram-negative pathogens. These agents are also sometimes used in neutropenic patients to treat MSSA while maintaining anti-pseudomonal prophylaxis when indicated. While in vitro activity is expected, there are limited data examining the clinical outcomes of these broad-spectrum β-lactams as targeted therapy for invasive MSSA infections.

Methods: This was a system-wide, retrospective, cohort study conducted at ECU Health assessing hospitalized adults with MSSA bacteremia. Included patients were treated with ≥ 7 days of monotherapy CZ or one of the following broad-spectrum β-lactams: TZP, FEP, ETP, or MEM between August 2019 and December 2025. Patients were excluded if they had MRSA isolated or if they received other antibiotics active against MSSA while receiving the study drug. Patients were identified using SlicerDicer within EPIC and then screened for inclusion. The primary outcome was treatment failure, defined as a composite of 90-day all-cause mortality, 90-day hospital re-admission, and 90-day recurrent MSSA bacteremia. Secondary outcomes included the individual components of the primary outcome at 30 days and 90 days, 90-day C. difficile infections, and new multidrug-resistant organisms isolated within 90 days.

Results: 1,435 patients with S. aureus blood cultures from August 2019 to December 2025 were screened. Of these, 33 patients on broad-spectrum β-lactams were eligible for inclusion (TZP=12, FEP=9, ETP=6, and MEM=6). 33 patients on CZ were then identified for balanced sample sizes, with a total of 66 patients included in the analysis. Average age, BMI, and duration of therapy, were similar between the two groups. The most common reason for exclusion was receiving the study drug for < 7 days (62%). Patients in the broad-spectrum group had nearly twice as long hospital length of stay compared to the CZ group (31 vs 17 days). Patients treated with broad-spectrum β-lactams were more likely to meet the 90-day primary outcome compared to those treated with CZ (OR 0.29; 95% CI 0.10-0.79; p=0.01). This was primarily driven by reduced 90-day mortality and 90-day re-admission.

Conclusion: This study showed a significant benefit in patients that received CZ over broad-spectrum β-lactams in the treatment of MSSA bacteremia. This study adds to the small amount of data comparing outcomes in patients with MSSA bacteremia treated with broad-spectrum β-lactams. Larger, prospective studies are warranted to further explore the most optimal broad-spectrum β-lactam for MSSA when additional coverage is needed.

Impact of GLP-1/GIP Receptor Agonists on HF-Related Hospitalizations 

Investigators: Haley Jones, PharmD; Erika Schoenborn, PharmD, BCCP, CPP; Kacy Whyte, PharmD, BCPS, BCCP
Practice Site: ECU Health Medical Center, Greenville, NC
Email: [email protected]

Purpose: Despite advances in guideline directed medical therapy (GDMT), many patients with heart failure (HF) experience persistent symptoms and recurrent hospitalizations. The intersection of HF and metabolic disease is of particular clinical importance, as type 2 diabetes mellitus (T2DM) and obesity are common comorbidities across the HF spectrum and are associated with worse clinical outcomes. Glucagon-like peptide receptor agonists (GLP-1 RAs) are an established treatment for T2DM and have recently gained prominence for their benefits in weight reduction and cardiovascular risk reduction. GLP-1 RAs reduce major cardiovascular events in patients with HFpEF, but conflicting evidence exists on the safety and efficacy in HFrEF. Further investigation is warranted to clarify their role in HF management. The purpose of this study was to assess the association between use of GLP-1 RAs and rate of HF-related hospitalizations for patients with HF.  
Methods: This retrospective cohort study included adult patients hospitalized with HF between January 1, 2024, and December 31, 2024. Patients were stratified by LVEF and by receipt of GLP-1 RA therapy. The primary endpoint was the rate of 30-day HF-related readmissions among patients receiving GLP-1 RA compared to those not receiving these medications. Secondary endpoints included 90-day HF-related readmission rates, time to first HF-related hospitalization, change in body weight during the study period, all-cause mortality, and administration of IV diuretics within 90 days. Patients were identified using SlicerDicer based on HF-hospitalizations within the study period, with outpatient prescriptions for a GLP-1 RA (tirzepatide or semaglutide) used to define the treatment group. Data were analyzed using descriptive statistics, Chi-Square, and Mann-Whitney U tests, as appropriate.  
Results: A total of 407 patients were screened for inclusion, with 106 patients included in each group. The median age was 69 yrs (IQR 60-77), 52% female, and 53.3% black patients. A total of 22 patients (20.7%) in the treatment group experienced 30-day HF-related readmission, compared with 19 patients (17.9%) in the control group (p = 0.60). Among patients with HFrEF, 30-day readmission occurred in 11 patients (22.9%) in the treatment group and 6 patients (15.8%) in the control group (p = 0.41). At 90 days, HF-related readmission occurred in 38 patients (35.8%) in the treatment group and 41 patients (38.7%) in the control group (p = 0.63). Median time to first HF-related hospitalization was 25 days (IQR 12-64) in the treatment group and 38 days (IQR 15-62) in the control group (p = 0.55). All-cause mortality occurred in 8 patients in the treatment group and 9 patients in the control group (p = 0.80). 
In the HFrEF subgroup, increased diuretic doses at 30 days were observed in 27 patients (60.0%) in the treatment group compared with 15 patients (40.5%) in the control group (p = 0.20), and at 90 days in 24 patients (58.5%) versus 14 patients (41.2%), respectively (p = 0.203). In the HFpEF/HFimpEF group, increased diuretic doses at 30 days occurred in 16 patients (37.2%) in the treatment group and 20 patients (41.7%) in the control group (p = 0.91), and at 90 days in 15 patients (37.5%) and 20 patients (46.5%), respectively (p = 0.62). 
Conclusions: In this retrospective analysis of patients with HF, GLP-1 RA therapy was not associated with differences in 30-day or 90-day HF-related readmission rates compared with no GLP-1 RA use. Although not statistically significant, a higher proportion of patients with HFrEF receiving GLP-1 RAs required increased diuretic dosing at 30 and 90 days, a pattern not observed in patients with HFpEF/HFimpEF. These findings suggest potential differences in clinical response by ejection fraction and highlight the need for further investigation into the safety and role of GLP-1RA in patients with HFrEF.  

Outcomes Associated with Early Versus Late Infectious Disease Consult for Staphylococcus aureus Bacteremia

Authors: Peyton Johnson, Alanna H. Rufe, Adam Harnden, Nancy Bailey, Sarah Vines, W. Creed Carleton

Purpose: Staphylococcus aureus is the most common Gram-positive cause of bacteremia and is a serious infection with up to 30% mortality. Optimal management of Staphylococcus aureus bacteremia (SAB) includes timely source identification, repeat blood cultures, echocardiography, and appropriate antimicrobial therapy. Infectious disease (ID) consultation is recommended as it is associated with improved patient outcomes, with some literature correlating earlier consultation with even better outcomes. At Jackson Hospital and Clinic most patients with SAB receive an ID consult, but the timing is variable. This study evaluated how timing of ID consultation impacts outcomes for patients with SAB.

Methods: This was an institutional review board approved, retrospective chart review at a 344-bed community hospital in Montgomery, Alabama. Adult patients were included if they had a diagnosis of SAB and received an ID consultation between October 1, 2023, and March 31, 2025. Patients were identified via a clinical decision support tool that reported blood cultures growing Staphylococcus aureus. Key exclusions included polymicrobial bacteremia, expiration within 72 hours of index blood culture, or refusal of treatment. Patients were stratified into two cohorts: early consult (ID consultation < 4 days from SAB diagnosis) and late consult (> 4 days).
The components of the primary composite endpoint were source identification, follow-up blood cultures, echocardiography within 5 days, administration of optimal parenteral antistaphylococcal therapy, and adherence to recommended treatment durations. Secondary endpoints included length of stay, in-hospital mortality, 30-day readmission, acute kidney injury, duration of inpatient antimicrobial therapy, and source-control procedures. Baseline demographics, comorbidities, and methicillin-resistant Staphylococcus aureus incidence were extracted. A priori power analysis estimated 88 patients to achieve 80% power. Additional statistical tests were used as appropriate.

Results: A total of 153 patient encounters were reviewed, and 93 patients met inclusion criteria. Among the included patients, 63 patients received an early infectious disease consultation, while 30 patients received a late consultation. Patients were excluded in the absence of ID consultation, polymicrobial bacteremia, death within 72 hours of admission, discharge against medical advice, and duplicate encounters. Baseline characteristics were similar between the early and late consultation groups, including age (60.3 vs 63.1 years), percentage of male patients (65% vs 63.3%), and incidence of methicillin-resistant Staphylococcus aureus (55.6% vs 56.7%).
Mean time to ID consultation was 1.9 days in the early group compared with 4.8 days in the late group (p < 0.0001). The primary composite quality-of care endpoint was achieved in 62% (n = 39/63) of the patients in the early consultation group compared with 53% (n = 16/30) in the late consultation group (p = 0.58). Acute kidney injury occurred significantly less frequently among patients who received early consultation (9.5% vs 33.3%, p = 0.01). No significant difference was found in length of stay, in-hospital mortality, 30-day readmission, duration of antimicrobial therapy, or source-control procedures between groups.

Conclusion: In this retrospective study of 93 patients with Staphylococcus aureus bacteremia, early ID consultation was not associated with a statistically significant improvement in the composite quality-of-care endpoint compared with later consultation. This may be due to an overestimation of the effect size. Early ID involvement was associated with a significantly lower incidence of acute kidney injury, which may support quality initiatives to standardize ID involvement. Implementing an automatic ID consult at the time initial blood cultures identify Staphylococcus aureus may reduce variability in quality-of-care and should be evaluated in future research.

Purpose: Carbapenem-resistant Acinetobacter baumannii (CRAB) is a high-priority antibiotic-resistant pathogen of public health concern and is associated with substantial morbidity and mortality. In 2024, the Infectious Disease Society of America (IDSA) recommended sulbactam-durlobactam in combination with a carbapenem as the preferred regimen for the treatment of CRAB. Despite IDSA recommendations, there isn’t a standard of care regimen for CRAB. Eravacycline, a synthetic fluorocycline, demonstrates structural resilience against common resistance mechanisms and shows in vitro activity against CRAB. This study aims to evaluate the clinical effectiveness of eravacycline-based therapy compared with best available therapy (BAT) in hospitalized patients with CRAB.
Methods: A retrospective chart review was performed on patients admitted to FMOL Health- Our Lady of the Lake with CRAB infections between January 2020 to December 2025. Patients aged 18 years and older with a documented infection of CRAB who receive one or more doses of eravacycline-based therapy or BAT were included. Patients were excluded if they were pregnant, did not receive antimicrobial treatment, discharged within 48 hours of admission, transferred to another hospital, or died prior to initiating antimicrobials. The primary outcome is a desirability of outcome ranking (DOOR) comparing eravacycline to BAT for treatment of infections caused by CRAB. The rankings are defined as the following: (1) clinical success without infectious complications or adverse events, (2) clinical success with infectious complications or adverse events, (3) absence of clinical success without infectious complications or adverse events, (4) absence of clinical success with infectious complications or adverse effects, and (5) death. Secondary outcomes include length of stay, duration of therapy, and relapse infection.
Results: A total of 271 patients were screened for eligibility. Of those evaluated, 96 patients were included in this study: 42 patients in the eravacycline group and 54 patients in the BAT group. The majority of patients were male (66.7%), black or African American race (51.04%), and had a median age of 60 years old. Most patients had at least one hospitalization in the 90 days prior to index hospitalization (65.6%) and had received IV antibiotics at least 90 days prior (60.4%). There was no significant difference between groups between any DOOR scale. The median length of hospital stay was 29.94 days, and the average length of therapy was 13.18 days. Repeat CRAB cultures were seen in 35.71% and 27.78% of patients in the eravacycline group and BAT group, respectively.
Conclusion: Among patients with CRAB, eravacycline did not appear to improve clinical outcomes or affect DOOR distribution.

Title: Impact of Health-System Community Pharmacists on Adherence for Medicare Advantage Plan Members 
Primary Author: Heather Vance 
Co-Authors: Catie Harper 
Practice Site: Cone Health Community Pharmacies and Triad HealthCare Network
Background: 
The Centers for Medicare and Medicaid Services (CMS) indicates quality of Medicare plans using a star-rating system, with one being the lowest and five being the highest. Three of the measures included in the star-rating system relate to patient medication adherence, including medication adherence to statins. CMS defines adherence as a proportion of days covered (PDC) of 80% or more.
Cone Health participates in value-based care agreements with payers to improve the quality of care provided to patients. Additionally, Cone Health sponsors a Medicare Advantage plan with Part D prescription drug coverage.
Through continuous evaluation, our organization identified that patients using integrated health-system pharmacies had improved medication adherence compared to outside pharmacies. Proactively, Cone Health began targeting patients failing or at risk of failing the statin adherence measure using health-system pharmacies to characterize the impact of targeted community-pharmacist intervention on plan member adherence.
Methods: 
This is an IRB reviewed, determined exempt, retrospective pre-post study evaluating medication adherence among members of a Medicare Advantage plan. Included patients were active plan members in 2025, with one or more statin fills at an integrated pharmacy, with Medication Adherence for Cholesterol measure PDC of 85% or less through the end of July 2025, identified through reports provided by the plan. Excluded patients were deceased, filling at non-health-system pharmacies, transitioned to hospice, or had therapy discontinued by their provider. The percentage of patients with PDC > 80% pre-intervention compared to post-intervention was the primary outcome, evaluated with McNemar’s Test. The number/type of pharmacist intervention was the secondary outcome, evaluated with descriptive statistics.
Patients received telephonic and electronic communication from the primary investigator regarding their prescribed statin therapy. After 3 unsuccessful attempts, patients were considered lost to follow-up. An adherence interview was conducted to assess understanding, tolerability, need for referral, and barriers to adherence. Patients were enrolled in appropriate adherence services. After enrollment, patients were contacted before their next refill to ensure sustained adherence.
Results: 
Of the 53 eligible patients, 19 patients were excluded. At baseline, the average age was 73.7 years, 50% of patients had clinical ASCVD, 55.9% had an LDL < 70 mg/dL, 50% had a PDC score of 65-79.9%, and 26.5% with PDC < 65%.
At baseline, 23.5% (n = 8) patients were considered passing the MAC measure with a PDC score > 80% compared to 41.2% (n = 14) after study completion. Of these patients, 7 were initially failing the MAC measure at baseline and were converted to passing. The final percentage of patients failing the MAC measure after study completion was 58.8% (n = 20), 19 of which were initially failing at baseline.
A total of 73 interventions were completed over the course of this study, with 53 conducted in the PDC < 80% group. The most common intervention was refilling other medications (n = 24), refilling targeted medication (n = 13), and leaving a voicemail with returned call (n = 13). The most common adherence service provided was automatic-refill enrollment (n = 5).
Conclusions: 
There was not a statistically significant difference between PDC scores among patients during pre- and post-intervention. This study encouraged the development of an adherence monitoring platform to ease monitoring and intervention for population health pharmacists. In the future, a single investigator driven intervention may not be sufficient to improve patient adherence, especially among larger cohorts.

Title: Tracking the Trends: Staphylococcus aureus Bacteremia Rates in a Rural, Not-for-Profit Hospital 
Authors: Natalie Ly, Heather Gibson, Allison Cid, Gretchen Arnoczy 
FirstHealth Moore Regional Hospital – Pinehurst, NC 
 
Background: Infectious Diseases (ID) consultation is associated with improved outcomes in Staphylococcus aureus bacteremia (SAB), yet access may be limited in community settings. This study evaluated SAB outcomes following interventions to increase ID consultation at a community health system. Interventions included increased ID availability for telemedicine consults, as well as a recommendation for ID consultation for all appropriate SAB cases. 

Methods: This retrospective chart review study utilized electronic medical records from FirstHealth patients with data collected from January 1, 2024 through January 31, 2025. All patients within the 4-hospital FirstHealth of the Carolinas system who had blood cultures positive for Staphylococcus aureus were evaluated. Patients were excluded if they met the following criteria: died or transitioned to comfort care within 3 days of positive blood culture, transferred to another institution, or were lost to follow-up. Patient characteristics and demographics were collected including age, sex, methicillin-resistant Staphylococcus aureus (MRSA), persistent bacteremia, persons who inject drugs (PWID), confirmed endocarditis, transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE), and ID consult status, as these are predictors of 6-month mortality for patients with SAB. The primary outcome studied was difference in 6-month mortality and recurrence rates, compared to rates observed within the hospital system during the COVID-19 pandemic. Secondary outcomes include differences in mortality or frequency of ID consults, particularly related to the implementation of ID telemedicine consults, as well as use of dalbavancin or oritavancin. 

Results: A total of 147 patients were included in this study. The 6-month mortality rate was 40/147 (27.2%), which was 5.9% lower than during the previous studied time frame; however, this was not statistically significant with a p-value of 0.25 (Relative Risk 0.82 [95% Confidence Interval 0.58-1.15]). Recurrence was defined as a return of SAB at least 2 weeks after resolution of the initial episode, as evidenced by documented negative blood cultures and improvement of clinical symptoms. The 6-month recurrence rate was 10/147 (6.8%), which was 2.5% lower than during the previous studied time frame. This was also a nonsignificant finding (Relative Risk 0.73 [95% Confidence Interval 0.34-1.56], p-value 0.42). The majority of patients 140/147 (95.2%) had an ID consult, as compared to 116/172 (67.4%) in the previous study. This 27.8% increase was statistically significant at a p-value of <0.001, with the rise in consult rates primary driven by telemedicine visits. There was also a higher incidence of cardiac imaging obtained and a trend toward shorter time to ID consult placed after positive blood culture. Utilization of long-acting lipoglycopeptides was low, as only 3 patients received dalbavancin and none received oritavancin.  
There are a number of factors that may have impacted the results of this study. Firstly, there were a small number of patients evaluated, which could make it more difficult to detect statistical significance when the study is not adequately powered. Furthermore, the population in this study included non-COVID patients, in contrast to the previous studied time period where patients had COVID-19 complicating their SAB. These patients may have differed in baseline illness severity, potentially biasing outcome comparisons.  

Conclusions: In this study, the expansion of ID access was associated with significantly higher ID consultation rates and favorable trends in 6-month mortality and recurrence rates among patients with SAB. These findings support the role of expanded ID access in improving SAB management within community health systems.

Title: Evaluation of Safety Outcomes in Patients with Diabetes Receiving Perioperative Dexamethasone  

Investigators: Christian Garner, Devon Johnson, Spencer Livengood
Practice Site: ECU Health Medical Center 
Contact: [email protected]

Background: Postoperative nausea and vomiting (PONV) occurs in ~30% of surgical patients and is more common in high-risk procedures. Intravenous dexamethasone is often utilized for PONV prophylaxis but may increase the risk of hyperglycemia in patients with diabetes. At ECU Health Medical Center (ECUHMC), cases of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) have been observed following perioperative dexamethasone use. However, the incidence of these complications remains poorly described in current literature. This research project aimed to evaluate the incidence of DKA and HHS in patients with diabetes receiving perioperative dexamethasone and identify associated risk factors for postoperative insulin drip initiation. 

Methods: This single-center, retrospective observational review evaluated adult patients with diabetes who underwent surgery and received perioperative dexamethasone at ECUHMC from July 2024 to July 2025. Patients were excluded for conditions likely to confound glycemic outcomes, including chronic steroid use, perioperative insulin infusion, or administration of additional steroids. The primary outcome was the incidence of postoperative DKA or HHS as defined by the 2026 American Diabetes Association. Secondary outcomes included hospital length of stay and mean 72-hour postoperative blood glucose levels. Descriptive statistics were used to summarize primary and secondary outcomes. A multivariate analysis was used to identify an association between independent variables and insulin infusion initiation. 

Results: Of 1,450 patients screened, 381 met inclusion criteria. Two patients (0.5%) developed confirmed DKA, and no cases of HHS were identified. Median postoperative length of stay was 92.2 hours and mean 72-hour postoperative blood glucose was 172 mg/dL, with 65.9% having a 24-hour postoperative blood glucose >200 mg/dL. Seventeen patients (4.5%) required initiation of an insulin infusion within 72 hours of dexamethasone administration but were missing necessary information to confirm DKA or HHS diagnosis. Results from the multivariate analysis confirmed higher admission blood glucose was independently associated with insulin infusion initiation (p=0.0435).  

Conclusion: Although perioperative dexamethasone use was associated with a low incidence of confirmed DKA and HHS, a notable proportion of patients required insulin infusion, indicating a higher burden of postoperative hyperglycemia and potential under-recognition of hyperglycemic crises. Elevated preoperative blood glucose levels were associated with increased risk of insulin infusion initiation, supporting closer perioperative glucose monitoring in patients with diabetes. 

Impact of Preconception GLP-1RA and Dual GIP/GLP-1RA Use on Insulin Requirements During Pregnancy in Patients with Type 2 Diabetes 
Authors: Kiera Rountree, Jessica Odom, Autumn Clemins, and Megan Schellinger
Practice Site: Prisma Health-Upstate 
 
Background 
Pregestational diabetes affect approximately 1–2% of pregnancies and is associated with increased maternal and neonatal morbidity. Achieving tight glycemic goals before and throughout pregnancy is essential to reduce the risk of congenital anomalies, abnormal fetal growth, hypertensive disorders, and delivery complications. Insulin requirements fluctuate during pregnancy due to physiologic changes in insulin sensitivity, with progressive insulin resistance typically emerging in the second and third trimesters. Insulin is the preferred treatment for diabetes in pregnancy; however, glucagon-like peptide-1 receptor agonists (GLP-1RA) and dual glucose-dependent insulinotropic polypeptide/GLP-1RA (GIP/GLP-1RA) are increasingly used in women of reproductive age for type 2 diabetes and obesity. Current guidelines recommend discontinuation of these agents prior to conception due to limited safety data, yet optimal timing of discontinuation remains unclear. Discontinuation may precipitate hyperglycemia requiring insulin initiation or escalation, and many pregnancies are unplanned, resulting in inadvertent early exposure. Data evaluating the impact of preconception GLP-1–based therapy on insulin requirements during pregnancy are lacking. This study aims to evaluate whether preconception exposure to GLP-1RA or dual GIP/GLP-1RA affects insulin requirements during pregnancy in patients with preexisting type 2 diabetes.

Methods 
This single-center, observational, retrospective cohort study included pregnant patients with preexisting type 2 diabetes enrolled in the Management of Maternal Diabetes (MOMs) program at Prisma Health Upstate between June 2023 and March 2025. Eligible patients were ≥18 years old with singleton pregnancies and documented GLP-1RA or dual GIP/GLP-1RA use within 60 days prior to conception, discontinued before or during early pregnancy. A comparator group without GLP-1–based therapy exposure was identified. Patients with gestational or type 1 diabetes, multiple gestations, insulin pump use, or incomplete insulin data were excluded. The primary outcome was the change in total daily insulin dose (units/kg/day) from baseline intake visit to the third trimester visit closest to delivery. Secondary outcomes included change in hemoglobin A1c, weight change, initiation and use of continuous glucose monitor (CGM), and maternal and neonatal outcomes. Data was collected through manual chart review, existing REDCap registry of MOMS participants, and pharmacy dispensing records. Statistical analyses were conducted with support from a statistician.

Results 
64 pregnant patients with type 2 diabetes were included; 13 (20.3%) had preconception GLP-1 receptor agonist exposure. Mean age (31.6 ± 6.2 years) and baseline BMI (37.4 ± 8.3 kg/m²) were similar between groups. Patients with preconception GLP-1 use were more likely to have hypertension (69.2% vs 31.4%, p=0.02) and obesity (76.9% vs 35.3%, p=0.01). Median total daily insulin dose increased from baseline to the third trimester from 0.3 (0.3–0.7) to 1.1 (0.8–1.5) units/kg/day. Patients with preconception GLP-1 exposure had higher insulin requirements at baseline (0.7 vs 0.3 units/kg/day, p=0.04) and in the third trimester (1.35 vs 1.0 units/kg/day, p=0.05). Hemoglobin A1c improved during pregnancy from 8.6 ± 2.0% to 6.4 ± 0.8%, with no differences between groups. A trend toward greater weight gain was observed in the preconception GLP-1 group (median 10 vs. 6 kg, p = 0.07), though not statistically significant. CGM use increased during pregnancy, with 43.8% of patients initiating CGM, and did not differ by exposure group. Maternal and neonatal outcomes were similar between groups; however, postpartum hemorrhage (15.4% vs 0%, p=0.04) and other major maternal complications (15.4% vs 0%, p=0.04) occurred more frequently in the preconception GLP-1 group. Neonatal complications were not significantly different.

Conclusion 
Preconception GLP-1-RA or dual GIP/GLP-1RA use was associated with higher insulin requirements throughout pregnancy, suggesting greater baseline insulin resistance. Glycemic targets and maternal and neonatal outcomes were similar, though greater weight gain was observed. These findings support early anticipation of increased insulin requirements, with proactive monitoring and timely dose titration to maintain glycemic targets.

Contact: [email protected]
 

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.  

Title: Identification of risk factors for beta-lactam resistant Pseudomonas aeruginosa bacteremia   

Background: Pseudomonas aeruginosa bloodstream infections (BSI) are associated with significant morbidity and mortality. Increasing resistance to antipseudomonal beta-lactams, including piperacillin-tazobactam, cefepime, and carbapenems, has complicated empiric treatment strategies.  Currently, institutional risk factors for beta-lactam resistant P. aeruginosa are largely derived from studies of respiratory isolates, which may not accurately reflect resistance patterns or risk factors in bloodstream infections. The goal of this study is to evaluate risk factors for beta-lactam resistant Pseudomonas aeruginosa bacteremia. 

Methods: This retrospective cohort study included patients 18 years and older within the Prisma Health system with a positive blood culture for P. aeruginosa from March 1, 2021 to August 31, 2025. The first positive blood culture within a 12-month period was included. Patients were excluded if they had cystic fibrosis. The primary objective of this study was to identify patient-specific risk factors for beta-lactam resistant P. aeruginosa BSIs (defined as resistance to cefepime or piperacillin-tazobactam). The secondary objectives were to identify risk factors for carbapenem-resistant P. aeruginosa bacteremia, determine predictors for isolates with elevated minimum inhibitory concentrations (MICs), and evaluate susceptibility patterns to novel antibiotics. Multivariate logistic regression was performed to determine independent predictors of beta-lactam and carbapenem resistance, as well as factors associated with isolates exhibiting elevated MICs. 

Research & Conclusion: In progress 

Evaluation of Inhaled Epoprostenol for Acute Respiratory Distress Syndrome in ICU
Gun Moon, Christen Freeman, Alston Poellnitz
DCH Regional Medical Center, Tuscaloosa, AL

Learning Objective: Identify the oxygenation response and appropriate utilization of inhaled epoprostenol in ICU patients with acute respiratory distress syndrome.

Self-Assessment Question:
Abrupt discontinuation of inhaled epoprostenol may lead to rebound pulmonary hypertension and worsening hypoxemia. True or False?

Background: Acute respiratory distress syndrome (ARDS) is associated with significant morbidity and mortality. Inhaled epoprostenol is used as salvage therapy. The study evaluated its impact on oxygenation, utilization, protocol adherence, and hospital outcomes.

Methods:
This IRB-exempt, single-center retrospective chart review study included adult ICU patients who received inhaled epoprostenol for ARDS at a 583-bed community hospital from January 2024 to August 2025. Patients required documented SpO₂ and FiO₂ values within 120 minutes before and 4 hours after initiation. The primary outcome was oxygenation response, defined as >15% improvement in SpO₂:FiO₂ at 4 hours. Secondary outcomes included appropriate use as salvage therapy, adherence to institutional titration/discontinuation protocol implemented in January 2025, ICU length of stay, ventilator-free days, and mortality.

Results:
Fifty patients were included with mean age of 60.4 years, with 70% of patients meeting severe ARDS criteria defined by PaO2:FiO2 <100. Seventeen patients (34%) met criteria for oxygenation response. Overall, 68% demonstrated increased SpO₂:FiO₂ from baseline, while 22% decreased and 10% showed no change. Appropriate use as salvage therapy was observed in 86% of patients. Appropriate titration/discontinuation occurred in 44.4% of patients prior to protocol implementation and 47.8% after implementation. Mean ICU length of stay was 9.1 ± 5.7 days, ventilator-free days were 20.7 ± 4.8 days, and mortality was 60%.

Conclusion:
Despite appropriate use as salvage therapy, inhaled epoprostenol demonstrated limited clinically meaningful improvement in oxygenation. Protocol adherence for titration and discontinuation remained inconsistent. Findings suggest the need for provider education, improved documentation, and evaluation of non-responders, including delays in discontinuations. Standardized discontinuation criteria may optimize use and reduce unnecessary resource utilization.

Resident e-mail: [email protected]

Title: Weight Loss Medication Tapering and Its Effect on Sustainability of Decreased Body Weight
Authors: Mary Christine Buehner, Paul Strange

Background:

Obesity affects the lives of more than 1 billion people worldwide. For this population, long-term maintenance of weight loss proves difficult as lifestyle modifications alone are often unsustainable due to components such as adherence and alterations in metabolism. Although management of weight loss with medications has proven to be effective for upwards of three years in previously completed randomized controlled trials, outcomes beyond the use of medications have not been consistently measured. Additionally, there is limited information available concerning the process of tapering individuals off of medication management and the corresponding long-term results associated with this method. The Ralph H. Johnson VA Healthcare System (RHJ VAHS) has previously utilized both the abrupt discontinuation and tapering off of weight loss medications, but it has yet to be determined which method allows patients increased maintenance of weight loss.

Methods:

This retrospective cohort analysis utilized Electronic Health Record (EHR) data available through the VA Computerized Patient Record System (CPRS) and the VISTA pharmacy database for all patients treated in a Ralph H Johnson VA Primary Care Clinic setting and prescribed an FDA-approved weight loss medication for the indication of obesity for at least 6-months between January 1, 2020, and February 1, 2025. Once evaluated, patients were allocated to two cohorts in a 3:1 fashion – those whose medications had been abruptly discontinued and those who had been tapered prior to discontinuation (or decreased to a maintenance dose appropriate for treatment of comorbid conditions). The primary endpoint was to determine if patients who were tapered off medications were able to maintain more than the abruptly discontinued cohort’s anticipated maintenance amount of 50% of total weight lost after treatment completion. The secondary endpoints analyzed weight loss between the cohorts over 10% at year two and 5% at year 3, as well as mean percentage of weight loss maintained at year 1, year 2, and year 3 (or end of study period). Other secondary outcomes considered in analysis were those patients lost to follow-up and those who were able to lose additional weight following year 1 therapy completion.

Results:

The primary outcome did not demonstrate statistical significance between the abruptly tapered cohort and the tapered cohort (53.8% maintained >50% total body weight loss at year 1 vs. 46.2%; OR 1.36 (0.97-1.91); p=0.0759). Secondary outcomes showed a significantly higher percentage of weight loss at year 1 in the abrupt cohort (-2.6±7.7% (median -0.7%) vs. -0.8±7.2% (median +0.5%); p=0.0082). However, data extraction determining efficacy became limited when a statistically significant increase in loss to follow-up impacted the tapered cohort from year 2 forward (69.8% vs. 57.4%; p=0.0034; OR=0.58).

Conclusion:

No significant difference was found in ability to maintain >50% of total weight loss at year 1 between patients abruptly discontinued and those tapered off of weight loss medications. Weight loss in subsequent years was difficult to analyze due to increased loss to follow-up in the tapered cohort demonstrating a need for consistent and efficient patient monitoring.

Title: Tirofiban use following mechanical thrombectomy with emergent stent placement in acute ischemic stroke
Author Names: Taylor Dodd, Mallory Stringer, Eric Shaw
Resident E-mail: [email protected]

Background
Tandem lesions are present in 15-25% of all acute ischemic strokes (AIS) presenting with a large vessel occlusion (LVO) and are associated with increased morbidity and mortality. Treatment of tandem lesions is not standardized, but may include intra-arterial thrombolysis, balloon angioplasty, and/or emergent stent placement during mechanical thrombectomy. Emergent stent placement requires antiplatelet therapy which may include glycoprotein (GP) IIb/IIIa inhibitors (e.g. tirofiban), aspirin, and/or P2Y12 inhibitors. Currently, there is inconsistent data regarding the dosing and duration of tirofiban infusion following mechanical thrombectomy with emergent stent placement in AIS. Retrospective data suggests similar rates of symptomatic intracranial hemorrhage (ICH), mortality, and reperfusion rates with tirofiban use compared to without tirofiban. The study objective is to evaluate the safety and efficacy of tirofiban followed by dual antiplatelet therapy (DAPT) compared to antiplatelet therapy alone in AIS patients post mechanical thrombectomy with emergent stent placement.

Methods
This was a single-center retrospective study conducted at a 711-bed DNV certified comprehensive stroke academic medical center. Adults admitted to the neurovascular intensive care unit (ICU) for AIS following mechanical thrombectomy and emergent stent placement that received tirofiban and/or antiplatelet therapy were included. Protected populations were excluded. The primary outcome was symptomatic ICH, defined as ICH on imaging with any of the following: need for neurosurgical intervention, intubation, decrease in Glasgow Coma Scale score ≥ 2 within 24 hours of tirofiban or DAPT. Secondary outcomes included any ICH, hospital and ICU length of stay (LOS), successful reperfusion (defined as a thrombolysis in cerebral infarction (TICI) score ≥ 2b), neurologic improvement (change in modified Rankin scale (mRS) from admission to discharge), and all-cause mortality.

Results
In this study, 56 patients were included with 27 patients in the tirofiban group and 29 patients in the group without tirofiban. Four patients (14.8%) in the tirofiban group compared to none in the without tirofiban group experienced symptomatic ICH within 24 hours of receiving tirofiban or DAPT (p<0.001). Any ICH was more prevalent in the tirofiban group compared to without tirofiban (51.9% vs. 6.9%, p<0.001). Hospital LOS (6.9 days vs. 6.1 days, p=0.386) and ICU LOS (3.8 vs. 3.7 p=0.444) were similar between groups. Successful reperfusion was achieved in 92% of patients in the tirofiban group compared to 84.6% in the without tirofiban group (p=0.668). Changes in mRS were not statistically different between groups (p=0.733). All-cause mortality was similar between groups (22.2% vs. 20.7%, p=0.837).

Conclusions
In our study population, the use of tirofiban had more ICH compared to patients not receiving tirofiban in AIS patients following mechanical thrombectomy and emergent stent placement.

Background 
Gram-negative bloodstream infections (GN-BSI) are associated with significant morbidity and mortality and traditionally managed with intravenous (IV) antibiotics. However, emerging evidence supports the use of oral (PO) antibiotics as step-down therapy in uncomplicated GN-BSI.1-7 Oral agents such as fluoroquinolones, sulfamethoxazole-trimethoprim, and β-lactams have demonstrated efficacy in this setting.1-2 Transitioning to a PO agent offers several benefits such as reduced cost, easier administration, and less risk of IV-associated complications, which include venous thrombosis, extravasation, and phlebitis.8-9 Despite these potential benefits, data on this practice in critically ill patients remain limited. This study aims to evaluate the safety and efficacy of IV therapy alone versus IV to PO step-down therapy in the treatment of critically ill patients with a GN-BSI. 
 
Methods 
This is a multicenter retrospective cohort analysis that evaluated adult patients with an uncomplicated GN-BSI who were initiated on appropriate empiric IV antibiotic treatment within 24 hours of their initial blood culture collection. The study included patients who were admitted to an intensive care unit (ICU) within Emory Healthcare (EHC) between May 1, 2023 and May 1, 2025. Patients were excluded if the duration of PO therapy was less than 48 hours, there was polymicrobial growth or presence of an organism other than Enterobacterales or Pseudomonas spp., hospice or comfort care was initiated within 72 hours of initial blood culture, or the organism(s) isolated was not susceptible to an available PO agent. The primary outcome was treatment failure, defined as a composite of 90-day mortality or recurrence of the same causative GN-BSI within 30 days of treatment completion. Secondary efficacy outcomes include ICU and inpatient length of stay, recurrence of GN-BSI within 90 days of treatment completion, emergence of resistance to study antibiotics, antibiotic duration, and IV to PO transition time. Secondary safety outcomes include adverse drug events leading to discontinuation or change in antibiotic therapy. Baseline demographics and outcomes were summarized with descriptive statistics while continuous data was summarized with means and standard deviations. 
 
Results 
Patients were separated into two cohorts based on antibiotic regimen: IV only (n=108) versus IV to PO (n=33). Baseline characteristics differed between groups, with patients in the IV only group demonstrating higher illness severity, depicted by higher median APACHE II (18 vs 14) and Pitt bacteremia scores (3 vs 2). The most common pathogens were Escherichia coli, Klebsiella pneumoniae, Serratia marcescens, Enterobacter cloacae, and Pseudomonas aeruginosa. Pulmonary sources were more prevalent in the IV only group, while genitourinary sources were more common in the IV to PO group. Treatment failure occurred more frequently in the IV only group compared to the IV to PO group (41.7% vs 15.1%). Recurrence of the same causative bacteria within 90 days was similar between groups (4.6% vs 6.1%), as was the emergence of resistance to study antibiotics (7.4% vs 9.1%). ICU and hospital length of stay were longer in the IV only group (13 vs 4 days and 21 vs 11 days). However, total antibiotic duration was longer in the IV to PO group (13 vs 9 days). Adverse drug events were uncommon in both groups. 
 
Conclusions 
While IV to PO step-down therapy was associated with lower rates of treatment failure, further research is needed to optimize treatment by determining appropriate drug selection and timing of transition. For critically ill patients with uncomplicated GN-BSI and adequate source control, this approach appears to be appropriate and may reduce length of stay without compromising effectiveness. These findings align with existing literature supporting PO step-down therapy as a method with comparable efficacy to continued IV therapy. 

Sedation Practices in Patients Undergoing Targeted Temperature Management at 36° C
Grace Clark, Anais Solomon, Joanna Brennan, Bibidh Subedi
AdventHealth Orlando, FL

Background: Targeted temperature management (TTM) is the practice of cooling patients’ core body temperature for comatose patients after cardiac arrest to prevent brain damage. Historically, patients undergoing TTM to a goal of 33° C have been deeply sedated with Richmon Agitation and Sedation Scale (RASS) goals of -4 to -5 to avoid shivering, which increases the cerebral metabolic demand. In 2013, the TTM trial was published, prompting the 2015 ACLS guidelines to include 36° C for TTM. TTM to 36° C reduces shivering and possibly sedation needs. The objective of this study was to characterize sedation practices during TTM at 36° C, focusing on RASS goals and the sedation level achieved.


Methods: This was a multicenter, retrospective cohort study with 75 patients from AdventHealth Central Florida campuses who were enrolled between 4/1/2025 and 9/30/2025. Adult patients 18 years of age or older were included if they received TTM at 36° C after out-of-hospital or in-hospital cardiac arrest. Patients were excluded if they were pregnant, had multiple cardiac arrests, or if they were placed on extracorporeal membrane oxygenation (ECMO). The primary outcome was sedation level achieved measured by the RASS score for five days post cardiac arrest. Secondary outcomes included prescribed RASS goal, if the RASS goal was changed during TTM, sedation medications utilized, cumulative doses of sedative medications, Glascow Coma Scale (GCS) at baseline and on day five, time to extubation, incidence of seizure, incidence of tracheostomy, ICU and in-hospital mortality, and ICU and hospital length of stay.


Results: All 75 patients were included in analysis. The average age of our patients was 62 years old with 68% being male. Witnessed arrests occurred in 77.3% of patients with 25.3% having a shockable rhythm initially. The median time to ROSC in witnessed arrests was 12 minutes. Around 61.3% of patients received vasoactive agents within 1 hour of hospital admission. The median RASS achieved was -2.5 on day 1 and 0 on days 2-5. The most common RASS goals were -1 to -2 (73.3%) and 0 to -1 (14.7%), with 29.3% of patients having their RASS goals changed during TTM. The most common continuous sedation medications were fentanyl (78.67%), propofol (76%), midazolam (58.67%), and dexmedetomidine (30.67%). The cumulative daily dose for dexmedetomidine increased over the first 72 hours, while fentanyl, midazolam, and propofol doses decreased. Patients were on sedative continuous infusions for a median of 36 hours with a TTM median duration of 72 hours. The number of patients on continuous sedation was 67 (89.3%), 48 (64%), 38 (50.7%), 25 (33.3%), and 16 (21.3%) respectively for days 1-5. The number of patients on as needed sedation was 8 (10.7%), 11 (14.7%), 11 (14.7%), 8 (10.7%), and 7 (9.3%) respectively for days 1-5. Around 37% of patients had TTM discontinued early with 5.3% of them due to the patient following commands. Median GCS was 15 at baseline and 10 on day 5. Seizures occurred in 19 people (25.3%) for a median of 2.63 days. Shivering occurred in 11 people (14.7%) and 8 people (10.7%) received tracheostomy. The median time to extubation was 2.7 days. The median lengths of stay were 4 days for the ICU and 7 days for the whole hospitalization. Mortality occurred in 46 cases (61.3%) with all the patients dying during their ICU stay.


Conclusions: Our study found that most patients undergoing TTM at 36° C had lower sedation targets prescribed and achieved than have been historically attained. Most patients were able to complete the full 72 hours of TTM. Further prospective studies are warranted to evaluate optimal sedation target in this demographic.

Presentation Objective: Analyze current targeted temperature management (TTM) sedation practices within AdventHealth Central Florida division.

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.

Optimizing Rabies Post-Exposure Management: Assessing Immunoglobulin Use and Vaccination Follow Up   

Quartney Gilliam, Mckenzie Hodges, Bianca Rivera-Ramirez, Aayush Patel 

Piedmont Columbus Regional Midtown, Columbus, GA 

Background: Rabies is a viral infection that is fatal without timely and proper intervention. Transmission most commonly occurs through the bite of an infected animal, with dogs representing the predominant source of human exposure. Current guidelines emphasize rapid and comprehensive post-exposure prophylaxis (PEP), which includes immediate wound cleansing, prompt administration of human rabies immunoglobulin (HRIG), and initiation of the vaccine series. Although PEP is highly effective when given appropriately and on time, its real-world implementation is often challenged by system level and institutional barriers. These include delays in starting treatment, late or missed doses of HRIG or vaccines, variability in provider adherence to protocols, poor patient follow-up, as well as significant strain on both patients and the healthcare system when navigating multiple visits across different facilities, possibly leading to confusion and fragmented care. To help reduce unnecessary repeat emergency department visits and improve continuity of care, patients presenting to Piedmont Columbus Regional Midtown (PCRM) or Piedmont Columbus Northside (PCN) emergency departments may be referred to Midtown Medical Clinic (MMC), a transitional care clinic, for follow-up rabies vaccinations. This study aims to evaluate the effectiveness of the current institutional rabies PEP protocols implemented at both PCRM as well as PCN, identify gaps in its application, and explore strategies to improve adherence, timeliness, and patient outcomes after a potential rabies exposure. 

Methodology: We conducted an IRB‑approved retrospective chart review of patients presenting to the emergency departments of PCRM or PCN from January 1, 2025, to December 31, 2025. This review included all patients who presented with a chief complaint of an animal-related bite or scratch. Patients were excluded if they transferred to another facility after evaluation or PEP initiation, left against medical advice, refused vaccination, or had insufficient documentation to determine exposure type, treatment, or follow‑up. The primary outcome measured adherence to CDC rabies PEP guidelines by determining whether eligible patients received indicated HRIG and/or vaccine and identifying both missed treatment and treatment given to patients who did not meet criteria. The secondary outcomes evaluated instances where clinical criteria for initiating rabies PEP were not met, follow-up compliance, and the rate and factors associated with referral to MMC for follow-up care. The outcomes were assessed using descriptive statistics.

Results: Among 200 screened patients (157 adults and 43 pediatric patients), eligibility for rabies post‑exposure prophylaxis (PEP) was identified in 42% of adults and 56% of pediatric patients. Among eligible patients, 77% of adults and 50% of pediatric patients were initiated on PEP, while 9% of ineligible adults and 10% of ineligible pediatric patients received PEP. Follow‑up after PEP initiation varied, with 25% of adults and 43% of pediatric patients completing the full vaccination series, and differences in follow‑up location observed based on the site of initial presentation.

Conclusions: In this evaluation adult rabies PEP initiation largely aligned with CDC guidance with most eligible adults receiving therapy and minimal use among those without indications. In contrast, initiation among pediatric patients meeting eligibility criteria was inconsistent. Across both age groups completion of the rabies vaccination series remained challenging, highlighting persistent barriers to follow‑up after initial PEP initiation.

Contact: [email protected]

Background: Stroke complicates up to 20% of traumatic blunt cerebrovascular injuries (BCVI), with the highest risk occurring within 72 hours of injury, underscoring the importance of prompt antithrombotic therapy. Current guidelines from the Eastern Association for the Surgery of Trauma and the Western Trauma Association recommend antithrombotic therapy but differ in preferred agents and dosing strategies. Prisma Health Richland’s (PHR) institutional guideline recommends aspirin monotherapy for BCVI grades I–III without specifying dose. Data comparing aspirin dosing in BCVI are limited. One retrospective study reported a 3.5% stroke rate with aspirin 81 mg, compared with previously reported rates of 2–8% using aspirin 325 mg. We sought to compare the incidence of ischemic stroke among patients with traumatic BCVI treated with aspirin 81 mg versus 325 mg. 
  
Methods: We conducted a retrospective cohort study of adult patients with traumatic BCVI treated with aspirin monotherapy at PHR from February 27, 2021 to September 30, 2025. Patients with stroke prior to aspirin initiation during index admission, inconsistent aspirin dosing within the first 7 days, or grade V BCVI were excluded. The primary outcome was ischemic stroke within 90 days of injury. Secondary outcomes included time to aspirin initiation, adherence to repeat imaging guidelines, worsening intracerebral hemorrhage (ICH), worsening solid organ injury, gastrointestinal (GI) bleeding, and in-hospital mortality. Baseline characteristics were compared using appropriate univariate analyses. Multivariable logistic regression was performed to evaluate the association between aspirin dose and ischemic stroke, adjusting for BCVI grade and time to aspirin initiation. 
  
Results: This study included 130 patients with a traumatic BCVI who were treated with aspirin therapy for stroke prevention. Of those included, 106 patients (81.5%) received aspirin 325 mg and 24 patients (18.5%) received aspirin 81 mg. Baseline characteristics were similar between the two treatment groups, with the majority being African American males. The most common mechanism of injury was motor vehicle collision (73.8%), followed by injury due to a fall (16.2%) and assault (1.5%). Concomitant traumatic brain injury was present in 46.2% of patients, while 13.8% of patients also had a solid organ injury. During the study period, 12 patients (9.2%) experienced an ischemic stroke. Ten of these patients received aspirin 325 mg, while 2 patients received aspirin 81 mg (p=1). Multivariate logistic regression with covariates BCVI grade and time to aspirin initiation demonstrated no different in the incidence of ischemic stroke with aspirin 325 mg (aOR 0.831, 95% CI 0.951-1.003). The majority of patients (94.6%) had repeat imaging completed within the 7-day timeframe indicated in our local BCVI guidelines. A new or worsening ICH occurred in 22 patients, the majority being in the aspirin 325 mg group (n=19; p=0.764), and a GI bleed occurred in 5 patients, all of whom received aspirin 325 mg (p=0.584). The overall mortality rate was 9.2% with 8 patients in the aspirin 325 mg group and 4 patients in the aspirin 81 mg group dying during the study period (p=0.225) 
 
Conclusion: This retrospective cohort study found that patients with a traumatic BCVI were more frequently treated with aspirin 325 mg compared to 81 mg, however, there was no significant difference in the primary outcome comparing the incidence of ischemic stroke between these two treatment groups. There was a non-significantly higher incidence of new or worsening ICH and GI bleed in the aspirin 325 mg group. These findings suggest that a larger study with more variance in aspirin treatment may be beneficial to validate a correlation between aspirin dose and incidence of ischemic stroke. 

Evaluation of Serum Phosphate Levels in ICU Patients Undergoing Continuous Renal Replacement Therapy
Katherine Fonfara, Eric Pyles, Rebecca Falter
AdventHealth Orlando, Orlando, FL
Background: Severe hypophosphatemia is associated with serious adverse effects such as skeletal muscle weakness, respiratory insufficiency, cardiac rhythm disturbances, and delirium. These complications have been linked to worsening clinical outcomes including failed extubations, increased time on mechanical ventilation, and increased intensive care unit (ICU) and hospital length of stay. Patients on continuous renal replacement therapy (CRRT) are at increased risk of experiencing hypophosphatemia and the corresponding complications.

Iatrogenic hypophosphatemia represents a modifiable risk factor that may potentially improve patient outcomes. This study aims to evaluate phosphate replacement strategies in critically ill patients on CRRT and characterize incidence and severity of hypophosphatemia. 

Methods: This evaluation was a single-center, retrospective study comparing rates of hypophosphatemia in adult patients requiring CRRT and those not on CRRT admitted to the ICU at a large community hospital. Patients who were admitted to an ICU and receiving CRRT for 24 hours or more were included in the treatment group. The control group included patients admitted to an ICU and not requiring CRRT. Patients with end-stage renal disease on chronic dialysis, nocturnal CRRT/sustained low-efficiency dialysis (SLED), or with confounding metabolic conditions were excluded from either group. The primary outcome was the percentage of hypophosphatemic levels, defined as serum phosphate level less than 1.9 mg/dL. Secondary outcomes included percentage of severe hypophosphatemic levels, defined as serum phosphate level less than 1.0 mg/dL, in-hospital mortality, hospital length of stay, ICU length of stay, and time requiring mechanical ventilation. A post-hoc subgroup analysis was conducted to compare the primary outcome based on average CRRT flow rates. 

Results: A total of 100 patients were included in the study, with 50 patients included in each group. The baseline demographics were similar between both groups except home diuretic use, and baseline phosphorus and serum creatinine levels. In the control group, the median baseline phosphorus level was 3.1 mmol/L (IQR 2.6-3.8), and the median baseline serum creatinine was 1.0 mg/dL (IQR 0.8-1.2). In the CRRT group, the median baseline phosphorus level was 5.4 mmol/dL (IQR 4.2-6.4), and the median baseline serum creatinine was 2.9 mg/dL (IQR 2.2-4.1). 

Regarding the primary outcome, the CRRT group had a significantly higher median percentage of hypophosphatemic levels compared with the control group (10.8% [0-29.3] vs 0% [0], p < 0.001). For the secondary outcomes, there was no difference in the median percentage of severely hypophosphatemic levels between groups (0% [0] in both groups, p = 0.317). The median hospital length of stay was longer in the CRRT group compared with the control group (14 days [7-24.8] vs 4.5 days [3-9.5], p < 0.001). Similarly, the median ICU length of stay was longer in the CRRT group (8 days [5-14] vs 3 days [2-7], p < 0.001). The median ventilator duration was also significantly longer in the CRRT group (4 days [3-8] vs 1 day [1-2], p < 0.001). In-hospital mortality was significantly higher in the CRRT group with 62% of patients dying during admission compared with 18% in the control group (p < 0.001). In the subgroup analysis of the CRRT group, there was no difference in percentage of hypophosphatemic levels across flow rate groups (< 20 ml/kg/h, 20-25 ml/kg/h, and > 25 ml/kg/h). 

Conclusions: Patients receiving CRRT were associated with a significantly greater percentage of hypophosphatemic phosphate measurements compared with control group. The CRRT group had higher phosphate levels at baseline and was associated with increased phosphate depletion. No association was observed between CRRT dialysate flow rate and the percentage of hypophosphatemic levels. These findings support the need for close phosphorus monitoring as well as early phosphorus supplementation.

Background:
Sepsis is a life-threatening condition caused by a dysregulated host response to infection, and septic shock represents its most severe form, carrying a high mortality risk. Intravenous (IV) hydrocortisone is recommended by the Surviving Sepsis Guidelines for patients requiring ongoing vasopressor support despite adequate fluid resuscitation. However, the optimal discontinuation strategy remains unclear as current guidelines do not specify whether hydrocortisone should be tapered or abruptly discontinued. Existing literature is limited and conflicting, and practice variability persists. This study evaluates the impact of hydrocortisone tapering versus abrupt discontinuation on recurrence of septic shock.
Methods:
This single-center, retrospective cohort study was conducted at Atrium Health Wake Forest Baptist Medical Center. Adult patients admitted to the Medical Intensive Care Unit (ICU) between September 2024 and August 2025 who received ≥ 8 doses or ≥48 hours of IV hydrocortisone for septic shock were included. Patients were categorized into two groups: taper (any dose reduction prior to discontinuation) or no taper (abrupt discontinuation). Resolution of shock was defined as maintaining a mean arterial pressure ≥65 mmHg without vasopressor support for ≥12 hours.
The primary outcome was recurrence of septic shock, defined as vasopressor reinitiation within 72 hours or escalation in vasopressor or hydrocortisone therapy. Secondary outcomes included duration of vasopressor therapy, ICU length of stay, hospital length of stay, and incidence of hyperglycemia (≥180 mg/dL). Continuous variables were analyzed using Wilcoxon rank-sum tests, and categorical variables using chi-square or Fisher’s exact tests, as appropriate.
Results:
A total of 43 patients were included (no taper n=30; taper n=13). Baseline characteristics were similar between groups, with no statistically significant differences in age, sex, vasopressor requirements, or severity markers.
Recurrence of septic shock occurred in 30% of the no-taper group and 38% of the taper group (p=0.7), demonstrating no statistically significant difference between strategies. Median duration of vasopressor therapy was similar (136 hours vs 123 hours; p=0.6).
There were no significant differences in secondary outcomes, including ICU length of stay (8 vs 7 days; p>0.9), hospital length of stay (18 vs 16 days; p=0.8), or incidence of hyperglycemia (70% vs 69%; p>0.9).
Conclusions:
In this retrospective cohort study, tapering of hydrocortisone did not reduce the recurrence of septic shock compared to abrupt discontinuation. No differences were observed in vasopressor duration, length of stay, or hyperglycemia. These findings suggest that routine tapering of hydrocortisone may not provide clinical benefit in this population. Prospective studies are warranted to confirm these findings and inform guideline recommendations.

Authors: Mikayla Texido, Jill Dunning, Caitlin Thomas
Purpose/Background: Hyperglycemia is commonly seen and associated with adverse outcomes among hospitalized patients, especially in the intensive care unit (ICU) because these patients are more vulnerable to poor outcomes. Previous trials demonstrate that improved glycemic management can reduce hospital complications, infections, and costs. In the critical care setting, guidelines recommend continuous intravenous (IV) insulin infusion as the preferred method for achieving specific glycemic goals while avoiding hypoglycemia. Despite these recommendations, there are limited studies that directly compare the safety and efficacy of IV insulin to subcutaneous (SubQ) insulin for glycemic management in the critical care setting. This study aims to evaluate patients who were eligible for IV insulin administration through an electronic glucose management system (eGMS) and compare those who were managed with IV insulin via eGMS versus those managed with SubQ insulin.
Methodology: This was a single center, retrospective chart review conducted at AdventHealth Orlando that evaluated patients in the ICU who received glycemic management with either IV or SubQ insulin from June 18, 2025, to August 18, 2025. Adult patients with either two consecutive blood glucose values ≥180 mg/dL or one blood glucose ≥300 while admitted to the cardiac, neuro, medical, surgical, or multi-system ICU were included. Patients were excluded if they were managed on IV insulin utilizing eGMS for less than 6 hours, were managed with IV insulin without eGMS, had cardiovascular surgery within 30 days prior to inclusion, or were being treated with insulin for diabetic ketoacidosis, hyperosmolar hyperglycemic state, or hyperkalemia. Patients managed with IV insulin through eGMS utilization were compared to those managed with SubQ insulin. The primary outcome was the percentage of blood glucose values within a goal range of 70-180 mg/dL. A total of 774 blood glucose values would provide 80% power to detect a 10% difference. Secondary efficacy endpoints included the time until blood glucose was in range, median blood glucose, and ICU length of stay in both groups, with time on eGMS and percent of successful transitions from IV to SubQ additionally evaluated in the IV group. Safety endpoints included the incidence of hypoglycemia (BG <70 mg/dL) and severe hypoglycemia (BG <40 mg/dL).
Results: Of the 431 patients screened, 149 patients met inclusion criteria and no exclusion criteria with 74 in the IV group and 75 in the SubQ group. The IV group had a total of 3,997 individual blood glucose values while the SubQ group had 1,599. Of the patients included, 82 (55.0%) were male, the median A1c was 6.7%, and the median blood glucose on ICU admission was 198 mg/dL. Blood glucose was within the goal range of 70-180 mg/dL in 79.9% of the measurements in the IV group versus 61.2% in the SubQ group (p<0.001). The median blood glucose in the IV group was 146 mg/dL versus 173 mg/dL in the SubQ group (p<0.001). Of patients who were able to maintain their blood glucose within goal range for at least 6 consecutive hours, the median time to blood glucose within goal range was 6.3 hours in the IV group (n=72) versus 14.0 hours in the SubQ group (n=60; U=1011; p<0.001). The patients in the IV group had a longer median ICU length of stay (7.5 days vs. 4.0 days; U=1877.5; p<0.001) and there were no incidences of severe hypoglycemia in either group.
Conclusion: Hyperglycemic patients admitted to the ICU had a higher percentage of blood glucose values within the goal range of 70-180 mg/dL with intravenous insulin administered via eGMS compared to patients managed with subcutaneous insulin.