2025 Southeastern Residency Conference

Title: Combating Resistant Pathogens: Exploring the Efficacy of Eravacycline Utilization in Multidrug-Resistant Infections
Authors’ names: Kiara Patino, Ryan Vathy, Ben Albrecht, Sujit Suchindran, Sarah B. Green
Background/Purpose: Eravacycline, FDA-approved for complicated intra-abdominal infections, is increasingly used off-label for multidrug-resistant (MDR) infections, including carbapenem-resistant Enterobacterales (CRE), Stenotrophomonas maltophilia and carbapenem-resistant Acinetobacter baumannii (CRAB). Eravacycline has been utilized at Emory Healthcare (EHC) hospitals, an academically affiliated healthcare system based in Atlanta, GA, for these MDR infections with limited treatment options. The objective of this study is to evaluate the efficacy and safety of eravacycline utilization for off label treatment of infections caused by MDR organisms at EHC hospitals.
Methods: This study is an institutional review board approved, multi-center, retrospective quasi-experimental analysis. Adult patients (≥ 18 years of age) who received eravacycline at an EHC hospital from October 1st, 2022, to June 30th, 2024, for the treatment of infections due to vancomycin-resistant Enterococcus (VRE), CRAB, CRE, MDR Enterobacterales, or S. maltophilia were included in this study. Patients who received < 72 hours of treatment with eravacycline were excluded. The primary endpoint was a composite of treatment failure defined as inpatient mortality during the index admission and/or 30-day microbiologic recurrence. Secondary outcomes included safety endpoints such as antibiotic associated adverse effects, infusion site reactions, and Clostridioides difficile infection diagnosis within 90 days. Descriptive statistics were used to evaluate the primary and secondary outcomes, and a multivariate regression analysis was used to assess risk factors for treatment failure with eravacycline.
Results: 48 patients were included in this study. The patients’ median age was 57.6 years, with 60.4% female and 54.2% Black. Eravacycline was primarily used for VRE (31.3%), S. maltophilia (29.2%), and CRE (20.8%) infections. The median treatment duration with eravacycline was 12.6 days. Treatment failure occurred in 39.6% of patients, while 60.4% of patient experienced survival without recurrence. Adverse events were rare (4.2%). No significant factors for treatment failure were identified in multivariate analysis.
Conclusions: Eravacycline is a well-tolerated option for treating MDR infections. Given its favorable safety profile, eravacycline is a promising alternative for infections with limited treatment options. 
Contact email: kiara.patino@emoryhealthcare.org  
 

Title: Longitudinal analysis of community-onset bacteremia due to ESBL-producing E. coli, K. oxytoca, K. pneumoniae, and P. mirabilis (2016-2024) 
  
Authors: Raveena Patel, Laura Leigh Stoudenmire, Bryan P. White, Cong Cheng, Xianyan Chen, Daniel B. Chastain  
  
Background:  
Bacteremia caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, and Proteus mirabilis is increasingly prevalent, limiting treatment options and worsening patient outcomes.  While prompt carbapenem therapy can reduce mortality in these infections, understanding temporal trends and patient-level risk factors is crucial for guiding empiric treatment and minimizing unnecessary carbapenem use.  However, specific clinical information regarding these ESBL-producing organisms as a cause of community-onset bacteremia remains limited.  This study investigates the evolving epidemiology of community-onset ESBL-producing bacteremia from 2016 to 2024. 
  
Methods: 
This retrospective cohort study included adult patients (≥18 years) presenting to Phoebe Putney Health System in Albany, Georgia, from January 2016 through November 2024 with community-onset bacteremia caused by ESBL-producing E. coli, K. pneumoniae, K. oxytoca, or P. mirabilis, defined by non-susceptibility to ceftriaxone according to antimicrobial susceptibility testing results.  Cases were included if the first positive blood culture was obtained during emergency department evaluation or within 48 hours of hospitalization. Patients with polymicrobial bacteremia, incomplete medical records, or transfer from another facility were excluded.  Only one isolate per patient per year was included to avoid duplication.  Clinical data were extracted from electronic health records using REDCap and included demographics, comorbidities, prior healthcare and antibiotic exposures, infection source, and severity of illness. Descriptive statistics and linear regression analysis were utilized to analyze data.
 
Results:  
A total of 127 cases of community-onset ESBL-producing E. coli, K. pneumoniae, K. oxytoca, or P. mirabilis bacteremia were identified.  E. coli was the most frequent isolate (83.4%, 106/127), followed by K. oxytoca (11.8%, 15/127).  The median age of the cohort was 67 years (IQR 58-77), with a majority being female (56.7%) and identifying as African American or Black (52.8%). The median Charlson Comorbidity Index was 5 (IQR 3-7). Most patients presented from home (77.8%) with a urinary source of infection (66.9%). Few patients (14.2%) had a prior history of ESBL-producing organisms in cultures within the preceding 1 year.  Antibiotic use was reported in 37.0% and 61.4% of patients within the prior 30 and 90 days, respectively.  Similarly, 39.4% and 60.6% had a hospitalization within the prior 90 days and 1 year, respectively. The overall prevalence of ESBL-producing isolates increased significantly from 6.8% in 2016 to 15.5% in 2024 (p=0.008), representing an approximate annual increase of 1%.  This upward trend may be attributed to multiple factors, including high comorbidity burden among patients (median Charlson Comorbidity Index, 5 [IQR, 3-7]) and recent healthcare or antibiotic exposure.  
 
Conclusion:  
This longitudinal analysis revealed a significant increase in the prevalence of ESBL bacteremia from 2016 to 2024.  A majority of the risk factors analyzed in this study were not statistically significant in explaining the rise of ESBL Bacteremia. Our study suggests that other factors were not analyzed in this study which could be contributing to the rise of ESBL bacteremia. Further investigation is needed to identify and understand other potential factors that may be contributing to the rise of the prevalence of ESBL bacteremia.  
 
Correspondence: rapatel@phoebehealth.com 
 
 

Title: Evaluation of the Necessity of Gram-negative Coverage in Skin and Soft Tissue Infections (SSTIs) 


Authors: Blake Wannarat, Rachel Langenderfer, Ryan Lally, Matthew Timmons, Brittany NeSmith, Eve Woodum, Olivia Whitworth, Michael Shaw


Background: Skin and soft tissue infections (SSTIs) range from mild to severe, involving microbial invasion of the skin and soft tissues. Most SSTIs are caused by gram-positive pathogens, including Staphylococcus aureus and beta-hemolytic streptococci. The Infectious Diseases Society of America (IDSA) guidelines recommend classifying SSTIs as purulent or non-purulent and by severity to guide targeted antimicrobial therapy, emphasizing S. aureus in purulent and streptococci in non-purulent cases. The objective of this study was to evaluate the necessity of empiric broad-spectrum gram-negative coverage in uncomplicated SSTIs at a community hospital in the southeast of the United States.  


Methods: This was a single center, retrospective cohort study. The electronic medical record system was utilized to identify hospitalized adults ≥18 years of age that were diagnosed with SSTI and received ≥3 days of vancomycin therapy between April 30, 2024 and October 30, 2024. The gram-positive group was defined as receiving ≥3 days of vancomycin therapy with or without ≤24 hours of gram-negative antimicrobial therapy. The gram-negative group was defined as receiving ≥3 days of vancomycin therapy plus broad-spectrum gram-negative antibiotics for >24 hours (i.e., 3^rd and 4^th generation cephalosporins, fluoroquinolones, piperacillin/tazobactam, and carbapenems). The primary outcome was the requirement of additional intervention, including escalation of antimicrobial therapy, antibiotics reordered for an additional course, or prolongation of inpatient antimicrobial therapy secondary to the index infection. The secondary outcomes were 90-day Clostridioides difficile infection occurrence, total duration of inpatient antimicrobial therapy for the index infection, and development of a resistant pathogen 90-days following index antimicrobial therapy. 


Results: A total of 66 patients were included in this study from a medical record review of 291 patients hospitalized with SSTI. Additional intervention was required in 2 of 10 (20%) patients in the gram-positive group and 13 of 56 (23.2%) patients in the gram-negative group. No patients in the gram-positive group required escalation of therapy or additional antibiotic courses; however, 2 (20%) patients experienced prolongation of inpatient antimicrobial therapy. In contrast, among patients in the gram-negative group, 1 (1.8%) patient required escalation of antimicrobial therapy, 1 (1.8%) patient had antibiotics reordered for an additional course, and 13 (23.2%) patients experienced prolongation of inpatient antimicrobial therapy. Patients in the gram-negative group had a numerically longer mean duration of inpatient antibiotic therapy (6.1 days) compared to those in the gram-positive group (5.1 days). Additionally, 1 patient in the gram-negative group developed a resistant pathogen 90-days following the index infection. Neither group experienced Clostridioides difficile infection within 90 days. 


Conclusion: Empiric broad-spectrum gram-negative coverage in uncomplicated SSTIs was associated with a higher likelihood of prolonged inpatient antibiotic therapy and extended treatment duration, without a clear clinical benefit over gram-positive coverage alone. These findings suggest that targeted gram-positive therapy is sufficient for most uncomplicated SSTIs and that empiric broad-spectrum gram-negative coverage may contribute to unnecessary antibiotic exposure. Furthermore, these results align with IDSA SSTI guidelines, reinforcing the recommendation for gram-positive coverage for most uncomplicated SSTIs and highlighting the potential risks of gram-negative broad-spectrum antibiotic use.

Authors: Gresham Hindman; Hannah G Harpe; Haley L Meek; Steven Le
 
Background: Fluoroquinolones are one of the most frequently prescribed antibiotics, contributing to developing resistance to gram-negative organisms. At McLeod Health, our antibiograms show poor susceptibility of Escherichia coli and Pseudomonas aeruginosa to levofloxacin. With poor susceptibility, a growing area of concern is prolonged duration of fluoroquinolones. To address this, a practice advisory alert was created to encourage providers to consider the days of equivalent antibiotics received while inpatient when prescribing a fluoroquinolone at discharge. The purpose of this study was to assess the impact of this alert on duration of fluoroquinolone therapy prescribed at discharge from McLeod Health.

Methods: This was an institutional review board approved retrospective, multi-center, single-system, pre-post cohort study of adults discharged on levofloxacin or ciprofloxacin from any McLeod Health facility. Subjects were identified utilizing a report from the electronic health record. Two reports were generated between August 2024 and February 2025, one prior to activation of the alert and the second post activation. Data was collected via an electronic, password protected spreadsheet accessible only to the primary study investigators. Patients were excluded if they were pregnant, received a fluoroquinolone prescription for prophylactic/suppressive use, or diagnosed with a severe/complicated infection. Data collection endpoints included patient demographics, infection type, antimicrobial management, infectious disease consultation, prescriber credentials, and readmission within 30 days with a Clostridioides difficile diagnosis. The primary outcome measure was incidence of inappropriate duration of fluoroquinolones prescribed at discharge according to current guidelines or infectious disease specialist recommendations, while accounting for inpatient antimicrobial use with equivalent coverage. The secondary outcome measure was the incidence of patients discharged on a fluoroquinolone and subsequently readmitted requiring treatment for Clostridioides difficile infection within 30 days of discharge. Derived from previous literature, a sample size of 540 patients was deemed necessary to obtain 80% power with an alpha of 0.05 to observe a 20% reduction of inappropriate durations prescribed at discharge.

Results: Two hundred participants were included in the study. Baseline characteristics were similar between both groups, however there was a difference in the infection type. The pre-practice advisory group had a higher incidence of urinary tract infections (38%) and intraabdominal infections (32%), whereas the post- practice advisory group had a higher incidence of pneumonias (40%). Of the 200 participants included, 151 (75.5%, 72 pre; 79 post) received inpatient antibiotic coverage that was considered equivalent to fluroquinolones. The most common agent used was ceftriaxone (pre 50% (36/72); post 56% (44/79)). The primary outcome, incidence of inappropriate duration of fluoroquinolones prescribed at discharge, occurred in 44% of patients in the pre-practice advisory group and 24% of patients in the post-practice advisory group, with an overall reduction of inappropriate prescribing by 20% (p=0.0028). Readmission in the pre- and post- groups were 12% and 6% respectively, however there was no incidence of Clostridioides difficile infections.

Conclusions: This retrospective cohort study demonstrated a statistically significant reduction in inappropriate durations of outpatient fluoroquinolone therapy through implementation of a practice advisory alert that notifies prescribers to consider the duration of antibiotic therapy received inpatient when prescribing fluoroquinolones at discharge. Our estimated reduction of inappropriate duration of therapy was 20% based upon a previous study, which we was met in this study. There was a statistically significant difference regarding the most prominent infection type between the groups, however this is attributed to the time of year data was collected from and respiratory infections being more common in the winter months. Overall, the practice advisory was effective and could potentially be expanded to other antibiotics in the future.

SERC Abstract: Limit of 600 words or less (not including title and authors).
Title: Impact of Comprehensive Education on Antibiotic Duration of Therapy for Community-Acquired Pneumonia in a Community Hospital
Authors: Keaton Prebble, Layla Marefat
Objective: Determine if pharmacist-led comprehensive education clinical pharmacists and hospitalists impacted the duration of therapy for community-acquired pneumonia.
Self-Assessment Question: The 2019 IDSA CAP guidelines recommend that if a patient is clinically improving, they may complete a total duration of therapy of:
Background: In 2019, the Infectious Disease Society of America (IDSA) released updated guidelines for the treatment of community-acquired pneumonia (CAP). These guidelines recommend a new preferred duration of therapy of no less than a total of five days if the patient has achieved clinical stability. Patients who receive extended antibiotic duration of therapy are at an increased risk of antibiotic resistance development and potential for adverse events. Many patients with CAP are likely to be discharged from an inpatient stay prior to completion of antibiotic therapy, and providers who prescribe antibiotics at discharge can, as a result, increase the duration of therapy when not indicated. This presents an opportunity for clinical pharmacists to intervene in both patients being discharged and those still admitted that it would be reasonable to receive only five days of therapy. This quality improvement project will determine whether comprehensive education to pharmacists and providers impacts the total duration of therapy of antibiotics for patients treated for CAP.
Methods: The study is an IRB-approved, retrospective cohort study. Patients who were hospitalized for at least 48 hours, had a diagnosis of pneumonia within 48 hours of inpatient admission, received antibiotic treatment indicated for pneumonia, and were at least 18 years old were included. Patients who were critically ill, had a palliative care consult during admission, had concomitant bacteremia, had received antibiotics for pneumonia for a separate admission in the last 14 days, or were immunocompromised were excluded.
Education was provided to clinical pharmacists during scheduled monthly meetings for a six-month period starting in August 2024. Hospitalists were educated in a separate meeting prior to post-intervention data collection. Data was collected from February 1, 2024, to July 31, 2024, and September 1, 2024, to February 28, 2025, via Slicer Dicer for the pre- and post-intervention groups respectively. The education consisted of both verbal and written materials that follow both the IDSA CAP guidelines and Baptist Health Lexington policies and procedures.
The primary endpoint was to evaluate the difference in mean antibiotic duration of therapy for patients with CAP in the pre- and post-intervention groups. The secondary endpoints were the difference in median duration of therapy for patients with an antibiotic switch, mean duration of therapy for patients with an outpatient prescription, initial procalcitonin, MRSA nares PCR ordered, sputum cultures collected.
Results: There were 116 and 145 patients from the pre- and post-intervention groups respectively. Overall mean duration of therapy decreased by 0.9 days after the intervention (7.3 ± 2.7 and 6.4 ± 2 days respectively in the pre- and post-intervention groups p = 0.005). Median duration of therapy decreased by one day for patients who had any antibiotic switch during admission after the intervention (7 days [IQR 6-10] and 6 days [IQR 5-8] in the pre- and post-intervention groups respectively p < 0.001). The mean duration of therapy for patients with an antibiotic prescription at discharge decreased by 1.5 days after the intervention (8.8 ± 3 and 7.3 ± 2.3 days respectively in the pre- and post- intervention groups p < 0.01). MRSA nares PCR was ordered for 66 and 76 patients in the pre- and post- intervention groups. Sputum cultures were collected for 36 and 39 patients respectively in the pre- and post- intervention groups.
Conclusions: The pharmacist-led education showed a statistically significant difference between the primary and secondary endpoints between the pre- and post-intervention periods.

Title: The Impact of Empiric Linezolid Compared to Vancomycin on Inpatient Outcomes  

Authors: Stacey Excellent, Jason Hoffmann, Pamela Andrews, Patricia R. Louzon    

Objective: Evaluate empiric linezolid compared to vancomycin on outcomes in the inpatient setting

Self Assessment Question: Which of the following is most likely to be impacted by the choice of empiric linezolid versus vancomycin in hospitalized patients?

Background: Vancomycin and linezolid are utilized for empiric methicillin-resistant Staphylococcus aureus (MRSA) treatment, but practical differences may influence the preferred choice. Vancomycin requires individualized dosing and monitoring, which can delay administration, while linezolid offers advantages such as cost, oral conversion, and standard dosing that may improve time to first dose. This research aims to compare patient outcomes with each agent to determine the optimal empiric choice.   


Methods: Eligible participants were those who received more than 1 dose of either vancomycin or linezolid during 3/1/2024 - 3/31/2024 and were stratified by level of care [intensive care unit (ICU) or non-ICU]. Excluded were those aged less than 18, had confirmed positive cultures, recent antibiotic treatment, or antimicrobial use for surgical prophylaxis. A convenience sample size of the first 50 patients (25 ICU and 25 non-ICU) meeting criteria per group were included. Baseline demographics were collected. The primary endpoint was to assess the impact of empiric vancomycin versus linezolid on inpatient mortality. Secondary endpoints included time to first dose, adverse events, therapy changes, duration of anti-MRSA coverage, length of stay (LOS), cost, vancomycin dosing characteristics, and the appropriateness of anti-MRSA coverage. The primary objective was analyzed using Chi-Square test. The secondary endpoints were evaluated using either Chi-Squared or Fisher's Exact test for categorical data and Mann-Whitney for continuous data. 


Results: Baseline characteristics were balanced between groups. Non-significantly more patients in the vancomycin group were on dialysis than linezolid (14% vs. 6%). Patients had fewer MRSA risk factors in the linezolid group than the vancomycin group with anti-MRSA therapy being classified as appropriate (based on risk factors) in 52% of linezolid patients and 64% of vancomycin patients (p = 0.224). The most common suspected source was pneumonia (n=40), followed by skin and soft tissue infections (n=26). The primary outcome of overall mortality was not significantly different between the vancomycin and linezolid groups (22% vs. 12%, p = 0.183). There was also no mortality difference when stratified by ICU and non-ICU. For secondary outcomes, the mean (SD) time to first dose was non-significantly shorter in the linezolid group vs. vancomycin [1.6 (1.7) vs.2 (1.5) hours] for the total population and stratified groups. Hospital LOS, ICU LOS and duration of anti-MRSA coverage were similar between the total population and stratified groups.  Incidence of adverse effects of renal dysfunction and thrombocytopenia were similar between groups and treatment failure was not seen in either group. Vancomycin patients had a mean (SD) of 2.8 (4) drug levels drawn which took a median of 54.6 hours to reach therapeutic range. Patients were in therapeutic range for an average of 29.5% of therapy with ICU having more time in range compared to non-ICU (53.6% vs 43.4%). The median cost of the medication was significantly higher in the vancomycin group ($46.59 [IQR: 24.83 – 79.70]) compared to the linezolid group ($29.52 [IQR: 17.83 – 46.22], p = 0.012). 


Conclusion: In this retrospective analysis, there was no significant difference in mortality between vancomycin and linezolid. Both agents showed similar efficacy, with no instances of treatment failure in either group. The incidence of thrombocytopenia and renal dysfunction was not different between groups. The medication cost of therapy was significantly lower with linezolid, demonstrating a cost-effective alternative to vancomycin, reducing direct medication cost. Overall, linezolid may offer an advantage as an empiric gram positive therapy option in terms of cost and resource utilization without compromising clinical outcomes. 

Title: C1 Esterase Inhibitor for Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema in Intubated Patients at a Community Teaching Health System


Authors: Christopher Reagin; Phillip Mohorn; Leslie Roebuck


Objective: Evaluate the use, clinical efficacy, and cost of C1 esterase inhibitors in patients intubated for ACEi-induced angioedema by assessing the duration of mechanical intubation


Self Assessment Question: What was the impact of C1 esterase inhibitor (C1EI) administration on the duration of mechanical ventilation in patients intubated for ACE inhibitor-induced angioedema?


Background: ACE inhibitor induced (ACEi-induced) angioedema is a rare but potentially life-threatening condition that can cause airway obstruction and require intubation. Its underlying mechanism involves bradykinin accumulation, leading to increased vascular permeability and tissue swelling. The management of ACEi-induced angioedema primarily focuses on supportive care, including airway management, cessation of the offending agent, and symptomatic relief. However, no FDA-approved treatments exist. C1 esterase inhibitor (C1EI) has been explored as a potential therapy, but its role remains unclear based on available literature. A retrospective analysis at our institution previously examined the efficacy of C1EIs in preventing mechanical ventilation in patients with ACEi-induced angioedema. Notably, some patients received the medication after they had already been intubated, which raised questions about the optimal timing of administration and its effect on outcomes, such as the duration of mechanical ventilation. This study aimed to assess C1EI’s effectiveness in intubated patients, focusing on duration of mechanical ventilation to clarify its clinical utility.


Methods: This was a retrospective, observational, cohort study conducted at a community teaching health system from January 2017 to August 2024. Patients intubated for ACEi-induced angioedema were identified through electronic health records and stratified into C1EI-treated and non-C1EI-treated groups. Both groups received standard of care (epinephrine 0.2 to 0.5 mg intramuscularly or 0.05 to 0.1 mg intravenously, corticosteroids at ≥ 50 to 100 mg hydrocortisone equivalent, a histamine-1 receptor antagonist, and a histamine-2 receptor antagonist). The primary outcome was duration of mechanical ventilation. Secondary outcomes included ICU length of stay (LOS), hospital LOS, in-hospital mortality, and angioedema-related medication costs. Continuous variables were analyzed using the Mann-Whitney U test, while categorical data were compared using Chi-square or Fisher’s exact test, with statistical significance set at p<0.05.


Results: A total of 22 patients met inclusion criteria (C1EI: 15, non-C1EI: 7). Median duration of mechanical ventilation was similar between groups (C1EI: 1.3 days [IQR: 1.1–1.6] vs. non-C1EI: 1.7 days [IQR: 1.3–2.3], p=0.078). No significant differences were observed in ICU LOS (C1EI: 2.3 days [IQR: 1.4–2.8] vs. non-C1EI: 3.0 days [IQR: 2.1–5.1], p=0.162), hospital LOS (C1EI: 4.1 days [IQR: 2.1–4.7] vs. non-C1EI: 3.5 days [IQR: 3.2–9.1], p=0.581), or in-hospital mortality (0% in both groups). However, median medication cost was significantly higher in the C1EI group ($12,743.8 [IQR: $9,117.5–$13,381.6] vs. $32 [IQR: $11.5–$68.5], p<0.001).


Conclusion: In this retrospective cohort study, the administration of C1EI did not significantly reduce the duration of mechanical ventilation or other clinical outcomes in patients intubated for ACEi-induced angioedema. However, its use was associated with substantially higher medication costs. Larger, prospective or propensity-matched studies are needed to clarify the role of C1EI in this patient population.

Title: Impact of Pharmacist Driven Ceftriaxone De-Escalation on Clinical Outcomes in Patients Hospitalized for Community-Acquired Pneumonia


Authors: Dana Olheiser, Avery Shawen, Ashley Byrd, Cameron Selent


Objective:


Self Assessment Question: Will implementation of pharmacist driven ceftriaxone de-escalation improve duration of treatment and hospital associated costs?


Background: The American Thoracic Society (ATS) / Infectious Diseases Society of America (IDSA) 2019 Community Acquired Pneumonia (CAP) Guidelines recommend a standard empiric intravenous (IV) regimen of a β-lactam plus a macrolide or an appropriate fluoroquinolone for the treatment of severe CAP. Specificities regarding the broadening or narrowing of antimicrobial therapies varies according to clinical severity, likelihood of pathogens and/or resistant organisms, and facility protocol. At Trident Medical Center, providers order empiric IV azithromycin and IV ceftriaxone for hospitalized CAP patients through predefined order sets. After 48-hours, if the patient is clinically stable and able to take oral therapy, IV azithromycin is de-escalated to oral therapy per pharmacist driven protocol. This study evaluates the impact of an adjunct pharmacist driven ceftriaxone de-escalation protocol.


Methods: 
This retrospective, single-center study evaluated the impact of the newly implemented pharmacist-driven  IV ceftriaxone de-escalation protocol in patients hospitalized for CAP. Patients were included if they were being treated for CAP with IV ceftriaxone and had already received 2 doses, were clinically improving, tolerating other oral medications, and had no other indications for treatment other than CAP. Patients will be de-escalated to amoxicillin/clavulanate if they have no known or reported history of penicillin allergy or to cefuroxime if they have a documented or reported mild to moderate allergic reaction to penicillin (excludes anaphylaxis and SJS/TENS).
This study analyzed primary endpoint of ceftriaxone de-escalation treatment success defined as improvement in white blood cell count (WBC), absence of fevers, and return to baseline oxygen requirements 24 hours after de-escalation. Additional secondary outcomes include time to de-escalation, duration of antimicrobial therapy and hospital length of stay. Safety outcomes include adverse drug reactions and 14-day readmission for CAP.  


Results: In progress


Conclusion: In progress

Title: Oral β-lactam versus Fluoroquinolone or Trimethoprim-sulfamethoxazole for Directed Short Course Therapy in Uncomplicated Enterobacterales Bacteremia
 
Authors: Colby Jordan Osborne, Allison M. Field, Christopher Dennis, David Laurent

Background/Purpose: Gram-negative bacteremia is prevalent and a significant cause of morbidity and mortality in hospitalized patients. Evidence suggests that transitioning to oral (PO) antibiotics after initial intravenous (IV) therapy results in comparable outcomes, while reducing hospital length of stay. Due to their favorable oral bioavailability, fluoroquinolones (FQs) and trimethoprim/sulfamethoxazole (TMP-SMX), have historically been preferred when selecting a PO agent. However, rising resistance rates and potential adverse effects may limit their use. Recent data suggest that PO β-lactam antibiotics may be an effective alternative. However, data on short course therapy with PO β-lactams remains limited. This study aims to evaluate the efficacy and safety of utilizing short PO β-lactam courses as directed therapy in uncomplicated Enterobacterales bacteremia.

Methods: This retrospective, cohort study assesses hospitalized patients ≥18 years of age with uncomplicated Enterobacterales bacteremia between January 1, 2020, and May 31, 2024. Patients receiving a short course, defined as 6 to 9 consecutive active antibiotic days, with transition to a PO β-lactam, FQ, or TMP-SMX as directed therapy with <96 hours of active IV therapy were included for analysis. The primary endpoint is a 30-day composite of treatment failure, defined as all-cause mortality, hospital readmission, recurrent bacteremia, or primary site infection due to the same microorganism. Secondary endpoints include individual components of the primary outcome at 30 and 90 days, as well as 90-day incidence of Clostridioides difficile infection (CDI) and multidrug-resistant organism (MDRO) colonization.

Results: Of 2046 patients screened, 281 patients (n=179 FQ/TMP-SMX and n=102 β-lactam) were included in the study. Baseline characteristics were similar between groups. The main source of infection was the urinary tract, with 79.3% in FQ/TMP-SMX group and 82.4% in β-lactam group. The most common pathogen identified was Escherichia coli (76.5% for both groups). The primary outcome occurred in 15/179 patients (8.4%) in the FQ/TMP-SMX group verses 8/102 patients (7.8%) in the β-lactam group (P=0.875). There were no statistically significant differences in secondary outcomes between groups, including 90-day all-cause mortality, hospital readmission, or recurrent bacteremia. Confirmed CDI at 90 days occurred in 1/179 (0.56%) in FQ/TMP-SMX group with no cases observed in β-lactam group.

Conclusion: Short-course oral β-lactam therapy demonstrated similar effectiveness and safety outcomes compared to FQ or TMP-SMX regimens in patients with uncomplicated Enterobacterales bacteremia. These findings support that in patients with uncomplicated Enterobacterales bacteremia, a 7-day treatment course utilizing a PO β-lactam for definitive therapy may be appropriate.

Assessing Average Time-to-Positivity for Monomicrobial Bloodstream Infections within an Institutional Health System 
Bailey M. Nero1, Chengwen Teng2, Erin Blalock2, Joseph Kohn1, R. Jake Crocker4, Majdi N. Al-Hasan1,3, P. Brandon Bookstaver1,2 
1Prisma Health Richland Hospital, Columbia, SC; 2University of South Carolina College of Pharmacy, Columbia, SC; 3University of South Carolina School of Medicine, Columbia, SC, 4Prisma Health Greenville Memorial Hospital, Greenville, SC 
Background: Bloodstream infections (BSIs) are associated with significant morbidity and mortality especially in patients with co-morbidities that can amplify the severity of the illness. Broad spectrum empiric antibiotics are initiated with suspected sepsis. Antimicrobial stewardship strives to optimize usage of antibiotics when indicated and create interventions to better antibiotic usage. However, there is lack of stewardship 

Title: Characterizing 24-hour pharmacist response to rapid multiplex polymerase chain reaction (rmPCR) blood culture results. 


Authors:
Noah Sanford
Elizabeth Covington
Rachel Friend
Mary Kate Lackey
Sarah Grace Gunter


Background: Rapid molecular polymerase chain reaction (rmPCR)-based blood cultures provide organism identification within hours of initial organism detection with proven positive impact on time-to-appropriate antimicrobial therapy and clinical outcomes. Pharmacist-driven rapid response programs to bacteremia identified by rmPCR have been studied with differing means of communication and limited hours of pharmacist coverage. Our study aimed to characterize 24-hour pharmacist response to rmPCR blood culture results with a focus on response differences between shifts and on time-to-appropriate antibiotics in patients hospitalized with resultant positive blood cultures.


Methods: This study was a single-center, retrospective chart review conducted on patients ≥19 years-old with positive blood cultures from November 25, 2022, to June 30, 2024, admitted to East Alabama Medical Center (EAMC). Patients were excluded if they were pregnant, prisoners, discharged or transitioned to comfort care within 8 hours of blood culture notification, or if they died within 24 hours of blood culture notification. Pharmacist shifts were divided into first (0700 to 1459), second (1500 to 2259), and third shift (2300 to 0659). The pharmacists at EAMC are alerted via Cerner when blood cultures result and review each positive result. Patients were identified using TheraDoc clinical surveillance software and randomized prior to screening for inclusion. Our primary outcome was percentage of patients requiring therapy modification after positive blood culture notification. Secondary outcomes included number and type of pharmacist intervention documented, time to pharmacist intervention, and time to optimal therapy. Between group comparisons were performed using the Chi-square, Fisher’s exact test, Mann-Whitney U test, and Kruskal Wallis depending on the data type and distribution. Normality was assessed by Shapiro-Wilk. To assess variables associated with a pharmacist intervention, a bivariate analysis was performed and variables with P<0.200 were included in logistic regression analysis. Statistical significance was defined by a 2-tailed p-value of less than 0.05. All statistical tests were performed using SPSS statistics software.


Results: After randomization, 150 patients were screened, and 30 patients were excluded leaving 120 patients for analysis. Baseline characteristics, including age, gender, race, Pitt bacteremia score, and Charlson Comorbidity Index, were similar among the three groups (first, second, and third shift). There was no difference in the primary outcome: 17 patients required therapy modification in the first shift group (31%), 15 (38%) in second shift, and 6 (24%) in third shift (p=0.516). Across the three shifts, there was no difference in number of patients with a pharmacist intervention documented (p=0.966), type of pharmacist intervention documented (p=0.175), time to pharmacist intervention (p=0.062) or time to optimal therapy (p=0.219). Pharmacists were more likely to intervene on patients with methicillin-susceptible Staphylococcus aureus bacteremia (odds ratio [OR] 5.7, 95% confidence interval [CI] 1.60 to 20.74) and less likely to intervene on patients with an infectious disease consult (OR 0.21, 95% CI 0.084 to 0.530). Pharmacist shift was not associated with likelihood of intervention.


Conclusion: Our study showed a similar need for therapy modification across shifts, with no difference in number or type of pharmacy interventions. Strengths of our study include assessing 24-hour pharmacist services and having all pharmacists intervening rather than just antimicrobial stewardship pharmacists. Limitations include a small sample size, potential delays in pharmacist documentation, reliance on manual intervention documentation, and the retrospective nature of the study. Future studies should further explore the benefit of 24-hour pharmacist response to positive rmPCR blood culture notifications.

Title: Impact of Cefoxitin Monotherapy Versus Traditional Antimicrobial Therapy on Time to Antibiotic Administration in Intra-amniotic Infections: A Retrospective Review
 Authors: Hannah Bischoff, Sarah Withers, Caroline Jozefczyk, Joseph Kohn, R. Jake Crocker, Jasmine Lewis, Carolyn Ellison, Alex Ewing, Pamela Bailey
Objective: Compare the time to antibiotic administration between cefoxitin and the standard of care therapy by measuring the time from when the antibiotic(s) were ordered to the completion of either cefoxitin administration or the completion of both ampicillin and gentamicin administrations.
Self-Assessment Question: Which of the following antimicrobial regimens for empiric coverage of suspected or diagnosed chorioamnionitis demonstrated faster time to administration?
Background: Intra-amniotic infections, like chorioamnionitis, are treated with antimicrobials to reduce maternal and neonatal morbidity and mortality. The American College of Obstetricians and Gynecologists (ACOG) recommends ampicillin and gentamicin as first-line therapy, with clindamycin in cesarean sections for expanded anaerobic coverage. Cefoxitin, a second-generation cephalosporin, offers robust coverage and is a recommended alternative agent. Studies have shown no significant differences in efficacy between cefoxitin and other treatments for obstetric infections. Due to concerns with traditional therapies, such as nephrotoxicity from gentamicin and Clostridioides difficile infections from clindamycin, cefoxitin has emerged as an effective single-agent alternative. A recent study in South Carolina demonstrated that cefoxitin is non-inferior to traditional antimicrobial therapy for treating chorioamnionitis. This study aims to compare the time to antibiotic administration between cefoxitin and traditional antimicrobial therapy of ampicillin and gentamicin, addressing a gap in research on timely treatment for intra-amniotic infections in alignment with ACOG's recommendation to administer antibiotics promptly upon diagnosis.
Methods: This multi-site, retrospective cohort study compared treatment outcomes for chorioamnionitis at Prisma Health sites in South Carolina. The pre-cefoxitin group, treated with ampicillin, gentamicin, with or without clindamycin from June 2022 to May 2023, was compared to the post-cefoxitin group, treated with cefoxitin from June 2023 to May 2024, following an update to institutional guidelines. All pregnant individuals aged 16 and older, with diagnosed or presumed chorioamnionitis, were included. 
Results: A total of 300 patients were included, 150 in both the traditional therapy and cefoxitin group. Baseline characteristics were similar between the traditional therapy and cefoxitin groups, with no statistically significant differences in age (25.4 ± 5.6 vs. 26.3 ± 6.0 years), race distribution, or length of hospital stay (3.3 vs. 3.2 days). Most patients in each group identified as White (45.3% vs. 41.7%), followed by Black (28.7% vs. 20.7%) and Hispanic (18.7% vs. 27.3%). The majority were not Hispanic or Latino (76.7% vs. 68.0%). Vaginal delivery was the most common mode of birth (63.3% vs. 55.3%), with similar rates of cesarean delivery (34.7% vs. 39.3%) and labor induction (62.0% vs. 58.7%). A negative Group B Streptococcus screen was reported in most patients (78.7% vs. 73.3%).
Receipt of antimicrobials within 60–90 minutes of order entry occurred in significantly more patients in the cefoxitin group compared to the traditional therapy group (69.3% vs. 4.7%, p < 0.001). Time to effective therapy was significantly shorter in the cefoxitin group (76.4 ± 93.3 vs. 183.7 ± 228.9 minutes, p < 0.001). Duration of therapy was similar between groups (1.25 ± 0.89 vs. 1.28 ± 1.32 days, p = NS). There were no statistically significant differences in ICU admissions (0 vs. 1 patient), mortality, 30-day infection-related readmission, or need for additional surgical/procedural intervention.
Conclusions: Cefoxitin use for chorioamnionitis significantly improves the time to effective antibiotic treatment, aligning with current guideline recommendations for prompt therapy. The absence of differences in secondary outcomes reinforces the clinical efficacy of cefoxitin, supporting its continued adoption as a first-line agent in the management of chorioamnionitis.

Title: Evaluation of Impact of Urinalysis Reflex to Culture Criteria Implementation
Authors: Morgan Vincent, Courtney Jackson, Emily Sinclair, Jeremy Frens, Cynthia Snider, Jeffrey Hatcher, Trung Vu, John Rizzo, Mike Boyer, Danielle Mahaffey, Andre Harvin 

Background/Purpose: Urinary tract infections (UTIs) are among the most common bacterial infections in both inpatient and outpatient settings, representing a significant burden on healthcare systems. Effective diagnosis and management of UTIs is imperative to improve patient outcomes. Although urinary symptoms are the mainstay of diagnosing UTIs, a urinalysis is often used as a supporting diagnostic tool. However, contamination, recent antibiotic use, and other acute illnesses can impact urinalysis and can be misleading, resulting in false-positives or false-negatives. Often, urine cultures are ordered despite the recognition of these drawbacks or lack of urinary symptoms, leading to unnecessary antibiotic prescribing. A recent cohort study conducted by Petty et al 2020 found that in 2,461 patients diagnosed with asymptomatic bacteriuria, 74.4% of patients received antibiotics and 80% of patients had urine cultures ordered. Previous literature also suggests urinalyses with WBC >5/hpf plus positive nitrites have a positive predictive value of 98% for positive culture. Additionally, the implementation of urinalysis reflex criteria reduces rates of urine culturing relative to control sites without increasing the rate of gram-negative blood stream infections. This project aims to analyze the effect of implementing reflex to urine culture criteria to reduce rates of unnecessary urine culturing in a community teaching hospital. 
 
Methodology: This multicenter, IRB-approved pre-post quality improvement study evaluated the impact of implementing conditional urinalysis reflex to culture criteria in an acute care setting. The reflex to culture was automatically cancelled if the urinalysis showed WBC <10/hpf or squamous epithelial cells >5/hpf. Patients were included if they had a urinalysis with urine culture ordered within the pre-intervention period November to December 2023 or a reflex order in the post-intervention period November to December 2024. Exclusion criteria were age less than 18, pregnancy, neutropenia (WBC <1.5 K/µL or ANC <1000/µL) or indwelling urinary catheter for greater than 5 days.  The primary outcome was proportion of urine cultures meeting reflex criteria. Secondary outcomes included days of ceftriaxone therapy, number of total urine cultures for cost-savings analysis, number of urine cultures ordered outside the reflex order, and number of patients with gram-negative bacteremia. A subgroup analysis of reflex orders by site (Emergency Department and Inpatient) pre-intervention and post-intervention was also conducted. The primary outcome was assessed via Chi-square analysis and secondary outcome were assessed with Wilcoxon rank sum or descriptive statistics. 
 
Results: A significant difference was found in all cultures that met reflex criteria in the pre- and post-intervention groups, with 53% of cultures meeting reflex criteria in the post-intervention group compared to 28% in the pre-intervention group (p<0.001). There was no difference between the pre- and post-intervention groups in overall cost savings, total number of ceftriaxone days (4969 vs 5613, p = 0.06), or in total incidence of gram-negative bacteremia (153 vs 156, p = 0.68). Sixty eight percent (3901/4517) of the total cultures post-intervention were ordered outside of the reflex order. In a subgroup analysis of reflex orders by location, the post intervention group had significantly more cultures that met reflex criteria than the pre-intervention group in either the Emergency Department or Inpatient locations.  
 
Conclusions: Implementation of a reflex to urine culture criteria significantly improved the overall quality of urine cultures collected but did not cause a difference in cost savings, total number of ceftriaxone days, or incidence of gram-negative bacteremia. 

Presentation Objective: Evaluate the Impact of Urinalysis Reflex to Culture Criteria Implementation at a Community Teaching Hospital
Self Assessment Question: True/False: A urinalysis is considered positive if it contains >10 WBCs /hpf and <5 SQCs/hpf.

Title: Differences in Duration of Treatment for Extended-Spectrum Beta-Lactamase (ESBL) Infections 


Authors: Natalee Chornak, Jen Tharp, Cameron Lanier, Edward Grace, David Cluck


Objective: Assess for differences in duration of treatment of ESBL infections from a urinary source


Self Assessment Question: In Progress


Background: With nearly 3 million cases of antimicrobial resistant infections in the United States per year, antimicrobial resistance has and continues to be a major public health threat, both nation and worldwide. Current Infectious Disease Society of America (IDSA) guidelines do not recommend different treatment durations for infections based on phenotypic resistance. The purpose of this study is to compare treatment of ESBL and non-ESBL infections from a urinary source and assess differences in treatment duration.


Methods: This study is a retrospective cohort study being conducted within 18 Ballad Health facilities between June 1, 2021 – June 30, 2024. Inclusion criteria consist of patients who are 18 years old or greater who had positive urine cultures for Escherichia coli or Klebsiella pneumoniae and received inpatient antibiotics for at least 24 hours. Exclusion criteria include patients who are pregnant, incarcerated, require use of a catheter, have urological abnormalities, conditions with inadequate source control, have a polymicrobial infection, have an indication for prolonged antibiotic treatment independent of current infection, or require Intensive Care Unit (ICU) level of care. Patients will be divided into two cohorts; those with urinary tract infection (UTI) only and those with bacteremia from a urinary source. The primary endpoint is a difference in duration of treatment of ESBL and non-ESBL organisms from a urinary source. Secondary endpoints include duration of antibiotic use, duration of treatment without a susceptible agent, hospital length of stay, readmission within 90-days, re-infection by the same organism within 90-days, and incidence of Infectious Disease consults placed.


Results: In Progress


Conclusion: In Progress

Title: Comparison of Rapid Diagnostic Tests on Antibiotic Use in Gram-negative Bloodstream Infections within an Academic Health-system
Authors: Colter Sheveland, Cassie Ferguson, Sarah Al-Mansi, Kayla Antosz, Caroline Jozefczyk, Andrew Gainey, Robert Daniels, Joseph Kohn, Chenweng Teng, Anna-Kathryn Burch, Majdi Al-Hasan, Brandon Bookstaver
Background: Gram-negative bloodstream infections (GNBSIs) lead to significant morbidity and mortality. Technologic advances in rapid diagnostic tests for pathogen identification and antimicrobial susceptibility testing (AST) have enhanced the ability for clinicians to more promptly initiate patients on stewardship-conscience and appropriate antimicrobial therapy compared with traditional culture and susceptibility methodologies. The purpose of this study was to evaluate the antimicrobial stewardship program benefit of the addition of the Accelerate Pheno® (AP) system for rapid phenotypic AST with an existing blood culture identification multiplex polymerase chain reaction (BCID2®)/Vitek 2®/ matrix-assisted laser desorption/ionization time (MALDI) workflow.
Methods: An IRB-exempt, multi-centered, retrospective, pre-/post-cohort study was conducted in adult patients hospitalized with aerobic GNBSIs at one of four Prisma Health – Midlands major acute care facilities. Notable exclusions were patients with polymicrobial GNBSIs, those who left against medical advice, transferred to an outside facility, discharged home, or died prior to receipt of antibiotic therapy initiation or blood culture identification results. Baseline characteristics and endpoints were manually collected using a pre-specified REDCap form. The primary endpoint of the time to first appropriate streamlined therapy (FAST) was evaluated in the AP group from August 5, 2022 to October 31, 2022 and in the post-AP group from May 1, 2024 to July 31, 2024. Key secondary endpoints included discordances between AP-determined and BCID2®- or MALDI-determined pathogen identification, discordances between AP-determined and Vitek 2®-determined AST results, and time to de-escalation off carbapenems, anti-pseudomonal beta-lactams, and Gram-negative combination therapy. 
Results: In Progress
Conclusions: In Progress

Title: Outpatient Parenteral Antimicrobial Therapy Adverse Events for Daptomycin Compared to Vancomycin 


Authors: Kristin Lanier, Jaspaul Jawanda, Allison Cid


Background: Outpatient parenteral antimicrobial therapy (OPAT) is defined as the administration of two or more doses of a parenteral antimicrobial agent outside of the hospital setting. Two commonly used antibiotics are vancomycin and daptomycin for treating gram-positive infections. The administration time of vancomycin is dose dependent and requires monitoring to assess for toxicity and therapeutic response. Daptomycin is administered as an intermittent infusion or an intravenous push. While creatine kinase levels should be monitored, daptomycin does not routinely require therapeutic drug monitoring. In patients where use of either agent would be appropriate, the differences in adverse event rates are unclear. 


Methods: A retrospective chart review was conducted between September 1, 2023 through August 30, 2024 at a 400-bed community hospital. Patients that have been treated within the FirstHealth of the Carolinas hospitals and the FirstHealth Infectious Diseases Clinic, that received either vancomycin or daptomycin in the OPAT setting within the 12-month time frame were identified. Patients with end-stage renal disease requiring continuous renal replacement therapy, that died during OPAT, or were pregnant were excluded. Demographic and clinical data was abstracted from the electronic health record. All patient data was in encrypted files with access granted only to investigators. The primary outcome studied was the occurrence of an adverse drug event resulting in a change in antimicrobial therapy or early discontinuation of therapy due to harm or injury. The secondary outcomes included a measurement of time to adverse drug event occurrence and total number of adverse events. The primary outcome was analyzed utilizing a Chi-square test. 

Results: Within the study, a total of 175 patients were included with 112 in the daptomycin group and 63 in the vancomycin group. For the primary outcome of early discontinuation of OPAT therapy, there was no statistically significant difference between the daptomycin and vancomycin groups (0.13 vs. 0.14, P = 0.87). The primary reason for early discontinuation in both groups was the occurrence of an adverse event. The daptomycin group demonstrated a shorter time to adverse event occurrence compared to the vancomycin group (12 vs. 30 days).  

Conclusions: When comparing the rate of early discontinuation between daptomycin and vancomycin in the OPAT setting, there was no significant difference between groups. These findings suggest either agent may be considered in the OPAT setting depending on patient specific factors. It is likely that utilization of a Bayesian model dosing software in conjunction with a dedicated OPAT clinical pharmacist, resulted in a reduction of adverse events in the vancomycin group.  

Title:  Evaluation of digoxin dosing and therapeutic drug monitoring in adult patients receiving continuous venovenous hemodiafiltration   


Author Names: Madison Nordin, Jenna Cox, Bryan Love, Breanne Mefford 


Background: Digoxin is a cardiac glycoside used in the treatment of heart failure and rate control to manage arrhythmias such as atrial fibrillation. The narrow therapeutic nature of digoxin is further complicated by renal dysfunction, leading to accumulation and toxicity, such as nausea, vomiting, visual symptoms (yellow-green discoloration), heart palpitations, bradycardia, and heart block. Currently, there is minimal evidence to guide digoxin dosing in continuous renal replacement therapy. Current recommendations are driven by data from a single case report of a patient administered digoxin while receiving continuous venovenous hemofiltration (CVVH) and expert opinion. The purpose of this study is to investigate the impact of digoxin dosing regimens on therapeutic drug monitoring for patients receiving continuous venovenous hemodiafiltration (CVVHDF).   


Methods: This single-system retrospective case study included patients 18 years of age or older admitted to a Prisma Health ICU from September 1, 2019, to September 1, 2024, who received digoxin during CVVHDF. Patients were excluded if they did not have a digoxin level drawn while receiving digoxin and CVVHDF. The primary objective of the study is to describe the impact of digoxin dosing on therapeutic drug monitoring in adult patients receiving CVVHDF. The secondary objective is to determine the safety and tolerability of digoxin for patients receiving CVVHDF by reviewing incidence of bradycardia (HR < 60 bpm) and administration of digoxin immune fab. The primary and secondary objectives will be analyzed using descriptive statistics. Medians and interquartile range (IQR) will be calculated for continuous variables and counts and percentages for categorical variables.   


Results: The initial data query yielded 44 patients. Six met criteria for inclusion, with ten levels drawn during CRRT. Half of patients (50%) received digoxin for the indication of heart failure and 66.7% were receiving amiodarone inpatient prior to the initiation of CRRT. The median CRRT effluent rate was 30.7 ml/kg/hr. The median digoxin level was 0.75 ng/mL overall and in patients who had levels drawn >72 hours after the first dose. Over half (80%) of the levels drawn occurred at least 72 hours after the first dose of digoxin. All digoxin levels over 1.2 ng/mL were drawn in patients who only received loading doses and were not started on maintenance regimens. The median total loading dose was 8.9 mcg/kg (using ideal body weight).  Loading doses ≥ 8 mcg/kg IBW (n=2) resulted in levels ≥ 1.2 ng/mL, whereas < 8mcg/kg IBW (n=1) resulted in levels < 1.2 ng/mL. Half (50%) of patients received a digoxin load but were not initiated on maintenance regimens. Of the patients that received maintenance therapy, all received 125 mcg every 48-hour regimens. All maintenance dose levels (n=7) on this regimen resulted in levels < 1.2 ng/mL. One-third (33%) of patients experienced bradycardic events while receiving digoxin and CRRT, and no patients received digoxin immune fab.


Conclusion: All maintenance digoxin regimens (n=3) administered were doses of 125 mcg every 48 hours. This maintenance regimen on CVVHDF yielded digoxin levels less than 1.2 mcg/mL. The findings of this study contribute to the paucity of data surrounding appropriate digoxin dosing for patients receiving digoxin while on CRRT, specifically CVVHDF.

Title: Impact of a provider specific antimicrobial utilization report on prescribing practices at a community hospital


Authors: Maks Lutsenko, PharmD, Linda Johnson, PharmD, BCIDP


Objective: The goal of this project is to determine whether provider antimicrobial use "report cards" are effective at increasing the appropriateness of antimicrobial use.


Self Assessment Question: (True/False) Antimicrobial Stewardship programs are critical services that pharmacists can play key roles in reducing the overuse and misuse of antimicrobials?


Background: Antimicrobial stewardship is essential for ensuring the responsible use of antimicrobials in clinical practice to preserve their effectiveness and combat the rising threat of antimicrobial resistance. Antimicrobial stewardship programs aim to optimize the treatment of infections by promoting the appropriate selection, dosage, and duration of antimicrobial therapy, while also minimizing the overuse and misuse of these critical medications. Novel stewardship interventions, such as provider antimicrobial utilization “report cards”, have shown promise in modifying clinician behavior, yet their effectiveness in reducing unnecessary antimicrobial use is underexplored. Our institution created and distributed a provider specific antimicrobial use report to rounding hospitalists. The report had an “all antimicrobials” and a “piperacillin/tazobactam and cefepime” specific comparative de-identified bar graph and was paired with education. The goal of this project is to determine whether this intervention was effective at increasing the appropriateness of antimicrobial use.


Methods: Adult inpatients receiving antimicrobial therapy and being followed by a rounding hospitalist was included. Patients were excluded if being managed by the infectious diseases service or by a hematology/oncology provider. Primary endpoint will be antimicrobial use per provider in the pre-and post-periods (all antimicrobials and piperacillin/tazobactam/cefepime). Secondary endpoints will be collected from a subset of patients to evaluate the overall appropriateness of antimicrobial use. 


Results: For our primary endpoint, we found a statistically significant reduction in overall antimicrobial use, and also within the subgroup of piperacillin/tazobactam and cefepime. Regarding our secondary endpoints, we found numerical improvements in appropriate usage with regards to pneumonia and intra-abdominal infection patient subsets. No adverse safety outcomes were noted.


Conclusion: The provider specific antimicrobial utilization tool was effective at reducing overall antimicrobial use and specifically the use of piperacillin/tazobactam and cefepime.

Title: Evaluation of duration of antibiotic therapy in cellulitis and abscess treatment

Authors: Taylor Luthringer, Rebecca Orr, Ashley Nebbia, Lauren Seymour

Background:  The Infectious Diseases Society of America guidelines recommend a five- to seven-day course of antibiotics for most skin and soft-tissue infections. In most cases of uncomplicated cellulitis, a five-day course of antimicrobial therapy has shown to be as effective as a ten-day course, if clinical improvement has occurred by day five. The purpose of this study was to evaluate the duration of antibiotics prescribed in the treatment of cellulitis at a community health system.

Methods:  This was a retrospective study of adults >18 yrs old admitted to a multi-campus community health system between January 30, 2024 and June 30, 2024 diagnosed with cellulitis and abscess based on International Classification of Diseases, Tenth Revision (ICD-10) codes. Patients with necrotizing fasciitis, pyomyositis, Group A streptococcal gangrene, osteomyelitis, or diabetic foot infection were excluded from the study.  Patient demographics, total antibiotic duration of therapy (inpatient and discharge), hospital length of stay, readmission rates, infectious disease consult rates, and other clinical data were collected via manual chart review.  Data was analyzed using descriptive statistics. 

Results: 
A total of 224 patients were included in the study.  One hundred sixty-two (72.3%) patients received greater than or equal to eight days of antibiotic therapy and 62 (27.7%) patients received less than eight days of antibiotic therapy. The average inpatient antibiotic duration was 65 hours (2.7 days) and the average discharge prescription duration was 176 hours (7.3 hours), with the total antibiotic duration resulting at 240 hours (10 days) on average. The most commonly chosen initial antibiotics were vancomycin, cefepime, and ceftriaxone.  Fifty (29%) patients were readmitted within 30-days of discharge.  The average length of stay was 3 days. 
 
Conclusion:  
The majority of patients included in the study (72.3%) received antibiotics for 8 days or more and, on average, were treated with a 10 day course of antibiotics. Discharge prescriptions were written for an average of 7.3 day duration, indicating that the length of therapy beyond the guideline-recommended duration is largely due to discharge prescriptions. These results indicate there is a substantial opportunity for clinical pharmacist intervention in ensuring the efficient utilization of hospital resources to improve guideline compliance and reduce unnecessary antibiotic exposure.

Title: 
Cost-Benefit Analysis of Inpatient Penicillin Allergy Assessment


Authors: Ted Holmes III; Melissa Padgett; Caitlin Ellis


Objective: 
Identify the positive effects of penicillin allergy de-labeling.


Self-Assessment Question: 
Which of the following has been associated with penicillin allergy de-labeling?


Background: 
Across most healthcare institutions, documented allergies result in avoidance of those medications, even if the reaction is unknown. However, up to 95% of patients either have an adverse effect incorrectly labeled as a penicillin allergy or have a childhood allergy. These inconsistencies put the patients at risk for receiving less effective treatment and adverse outcomes. To make matters worse, these alternative therapies may also increase costs for the patient and the facility. The purpose of this study is to analyze the cost impact of patients with documented penicillin allergies who are receiving inpatient antibiotics.


Methods:
This is a single-center, cost-benefit analysis conducted at a 515-bed academic hospital. Adults who were prescribed antibiotics and had a documented penicillin allergy or intolerance were included. Patients were excluded if they received antibiotics for less than 48 hours (both cohorts) or those who were unwilling or unable to participate in the interview (penicillin allergy clarification cohort only). Included patients were divided into two cohorts: those who received penicillin allergy clarification (pharmacy intervention) and those who did not receive an intervention. The primary endpoint was the total cost of antibiotics calculated from the average wholesale price, derived from publicly available resources. The secondary endpoints were antibiotic days of therapy and hospital length of stay.


Results:
Two hundred and sixty-eight patients were included in the study. The primary outcome of total cost of antibiotics was $240.80 and $254.60 for cohorts 1 and 2 respectively (p=0.7270). Cohort 1 had an average of 9.7 days of antibiotic therapy as compared to 8.9 days in Cohort 2 (p=0.4783). The average length of stay was 6.7 days in Cohort 1 and 5.6 days in Cohort 2 (p=0.0886).


Conclusion:
Although there was no statistically significant difference between any of the outcomes, there was a trend towards higher utilization of penicillins and lower utilization of carbapenems in patients who had their allergy clarified. As seen in other studies, potential cost savings may be due to the shorter length of hospital stay observed in patients who have had their allergy clarified. Larger studies are warranted to determine the true financial implications of penicillin allergy de-labeling.


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