2025 Southeastern Residency Conference

Title: Analysis of Prosthetic Joint Infections in a Community Hospital  
Authors: Sydney Hege, Heather Gibson, Allison Cid, Gretchen Arnoczy 


Background: Joint replacement surgery has become a common surgical procedure for patients and improves independence, mobility, and quality of life. Prosthetic joint infections (PJIs) are a serious complication of prosthetic joint implantation and must be managed appropriately. Management of infections vary from practice to practice and current guidelines offer a range of recommendations. This study aims to compare the treatment of PJIs at FirstHealth of the Carolinas to current guideline recommendations. 

Methods: Eligible participants were identified via retrospective chart review using electronic medical records from March 1st, 2022, through September 30th, 2023. This 18 months of data was censored at 12 months post-infection and included data from all FirstHealth of the Carolinas facilities. Patients were included if they were ≥ 18 years old, diagnosed with a PJI at FirstHealth, treated by an Infectious Disease (ID) physician, and discharged on outpatient parenteral antibiotic therapy (OPAT). Only pregnant patients were excluded. The primary objective was to analyze initial antimicrobial treatment duration of PJIs, utilization of rifampin in staphylococcal infections, and use and duration of suppressive antimicrobials compared to Infectious Diseases Society of America (IDSA) guideline recommendations. Secondary objectives include evaluating Clostridioides difficile infection (CDI) rates, antimicrobial complications, and prolonged or recurrent infection within 12 months of surgery for confirmed PJI. All data collected was de-identified and only the primary investigators have access to the data via a password encrypted file.


Results: A total of 95 patients were identified. 10 patients were duplicates, leaving 85 patients included in this IRB-exempt study. Patient characteristics evaluated included age, gender, body mass index (BMI), type of prosthetic joint, diabetes diagnosis, time since initial surgery to diagnosis of PJI, and tobacco use.  The majority of PJIs were categorized as late infections (47%), followed by delayed (27%), and early infections (22%). The main prosthetic joints infected were knee (64%) followed by hip (27%), while causative organisms included staphylococcus aureus (37%), followed by non-aureus staphylococcus (22%) and streptococcus species (14%). PJI procedures included debridement, antibiotics, and implant retention (DAIR) (31%), 1 stage (41%), 2 stage (2%), and our modified 2 stage procedure (22%). During this time frame, 2200 hip and knee surgeries were performed at FirstHealth. Out of 85 PJIs, 45 patients had their initial surgery at FirstHealth, estimating an annual rate of PJIs at FirstHealth of 0.83% compared to 1-2% in the U.S. The initial intravenous (IV) antimicrobial treatment duration of 4-6 weeks per IDSA guidelines was achieved in 82 of 85 patients (96%), while the use of adjunctive rifampin for staphylococcal PJIs was utilized in 15 of 39 eligible patients (38%). The use of suppressive oral antimicrobials after IV therapy is recommended in DAIR or 1 stage procedures and 54 of 61 eligible patients (89%) received suppression. The secondary objectives included a CDI rate of 1 in 85 patients (1.2%), 16 reported IV antimicrobial complications, and 9 of 85 patients (10.6%) experienced a prolonged or recurrent infection. 


Conclusion: In this study, results show that FirstHealth’s current standard of practice for managing PJIs mostly aligns with IDSA guideline recommendations. Of note, there is room for improvement in our duration of oral suppression and rifampin utilization in managing these infections. However, there were low rates of complications, including CDI, as well as a low rate of prolonged or recurrent infection in this population. Further steps should be taken to assess the need for a standardized protocol for the treatment of PJIs at FirstHealth of the Carolinas.

Title: 
LVADing the Way: Narrowing Antibiotics Without Increasing Infection Risk


Authors: 
Shyam Patel; Dusty Lisi; Mahmoud Abdou


Objectives: 
To evaluate the impact of different antimicrobial prophylaxis in patients undergoing LVAD implantation on infection free survival. 


Background: 
Driveline infections are one of the most serious and common complications associated with left ventricular assist device (LVAD) implantation. With an increase in prevalence of LVADs being used as a bridge to heart transplant or as destination therapy in end-stage heart failure, there is growing concern about optimizing perioperative antimicrobial management in LVAD procedures to prevent driveline infections and LVAD-associated infection (LVADI). Current guidelines for surgical infection prophylaxis (SIP) for LVAD implantation are not well established, leading to varied SIP regimens including single and multi-drug regimens covering the common pathogens such as Staphylococcus aureus, Staphylococcus epidermidis, Klebsiella pneumoniae, and Enterobacter species. Institutions may also opt to cover for rare fungal and Pseudomonas infection based on institution-specific pathogen prevalence and antimicrobial resistances.

Broad spectrum antimicrobials have been the regimen of choice for LVAD SIP; however, the overuse of antimicrobials has led to several undesirable outcomes such as antimicrobial resistance and increased healthcare costs with questionable effects on patient outcomes. Several recent studies have found that narrow LVAD SIP regimens did not impact the infection-free survival or all-cause mortality as compared to different multi-drug regimens.

On August 13th, 2023, Emory Healthcare changed its SIP for LVAD implantations. This updated protocol replaced the previous regimen containing micafungin, vancomycin, and cefepime/levofloxacin with one that contains vancomycin and cefuroxime. The goal of this study is to evaluate the effectiveness of this new narrower drug regimen without pseudomonas and fungal coverage and its outcome on infection-free survival and mortality in LVAD patients at our institution compared to the previous multi-drug broad spectrum SIP. 


Methods:
A multi-center, retrospective chart review IRB-approved study was conducted to analyze patients meeting inclusion criteria pre- and post-implementation of a standardized LVAD SIP protocol (August 13th, 2023). Included patients who were at least 18 years of age and had received either a HeartMate 2, HeartMate 3, or HeartWare device at Emory Saint Joseph’s Hospital or Emory University Hospital. Patients were excluded if they did not have antimicrobial prophylaxis documented at the time of LVAD surgery, were receiving antimicrobial therapy 2 weeks prior to LVAD implantation for a previously diagnosed infection or had with concerns for infection prior to procedure. The primary outcome was time-to-infection. Secondary outcomes included percent driveline infection within 1st year, time-to-mortality,  infection type, and organism type. 


Results (pre-protocol vs post-protocol implementation): 
Ultimately, 62 patients were included in the pre-protocol implementation group and 18 patients in the post-protocol implementation group. Baseline demographics were similar between the two groups with the exception of a lower BMI in the pre-protocol group (27.6 vs.29.8 kg/m², p=0.04) and a higher percentage of individuals requiring pre-operative mechanical support in the pre-protocol group (65% vs 39%, p=0.01).There were a greater percentage of documented LVADI in the pre-protocol group (37% vs 33%); however, this was not correlated to a decreased time to infection between the pre-protocol and post protocol groups (267 vs 454 days, p=0.76). Both groups had similar percentage of mortality (15% vs 17%) with no difference in time to mortality (1847 vs 423 days, p=0.85).


Conclusions: 
Following the implementation of a protocol to narrow LVAD SIP by replacing the previous regimen containing micafungin, vancomycin, and cefepime/levofloxacin with one that contains vancomycin and cefuroxime for LVAD surgeries, there was no change to time to LVADI or mortality. Despite the small sample sizes and the differences in their sizes, this antimicrobial stewardship strategy was successful in reducing improper antimicrobial use across out healthcare system without compromising patient outcomes.

Title: Doxycycline Versus Azithromycin for Chlamydia Treatment in the Emergency Department 

Authors: Paakhee Shah, Dora Hall, Sarah Cullen 

Background/Purpose: 
Chlamydia is a sexually transmitted infection with a high rate of incidence, and most commonly affects those 24 years old and younger. It can often present asymptomatically, so it is important to test and treat patients routinely. Untreated chlamydia infection can cause complications such as pelvic inflammatory disease, ectopic pregnancy, and infertility. Before the 2021 Sexually Transmitted Infections (STI) Treatment Guidelines were released by the Centers for Disease Control and Prevention (CDC), the treatment of choice for chlamydia infection was a one-time oral dose of azithromycin 1 gram. With its continued use, Chlamydia trachomatis has developed resistance to azithromycin, especially in patients with rectal infection. The 2021 CDC STI Treatment Guideline recommends using doxycycline 100 mg orally twice daily for 7 days, which is highly efficacious in urogenital, rectal, and oropharyngeal infections. Azithromycin should still be used as an alternative in pregnant patients, in patients where nonadherence is a high concern, or patients with an allergy to doxycycline. 
A previous evaluation of prescribing according to the CDC Guidelines at Emory Decatur Hospital (EDH) and Emory Hillandale Hospital (EHH) showed that 66% of patients received doxycycline and azithromycin double coverage inappropriately. As a result of the evaluation, an order panel was developed to prompt providers to prescribe doxycycline over azithromycin, unless indicated otherwise. This study's purpose was to determine if the increased use of doxycycline reduces treatment failure incidence and contributes to better patient outcomes.  

Methods: 
This single-center, retrospective cohort study aimed to evaluate the impact of the updated CDC guidelines and hospital order panel on re-infection rates and treatment failure. Outcomes compared two cohorts: cohort one included 224 patients who were treated for Chlamydia infection in the emergency department with only doxycycline and cohort two included 40 patients who were treated for Chlamydia infection in the emergency department with only azithromycin. The primary outcome was treatment failure or re-infection rates, defined as having a subsequent positive NAAT test three to four weeks after initial diagnosis. Secondary outcomes included order panel and CDC guideline adherence and prescribing patterns of doxycycline versus azithromycin.  

Results: 
The incidence of treatment failure in the doxycyline group was 0.9% (n=2) and 5% in the azithromycin group (n=2) (OR 5.8, 95% CI [0.8-42.7], p-value 0.11) with a power of 0.3. For secondary endpoint of appropriate antibiotic use following the placement of the order panel, 88.3% of patients received the appropriate antibiotic selection, 9.1% of patients received azithromycin inappropriately, and 2.7% of patients had a treatment duration of longer than 7 days. Of the 173 patients that were screened to determine the secondary endpoint incidence of double coverage following placement of the order panel, 1.7% of patients received double coverage (n=3).  

Conclusion: 
The study was not adequately powered to identify a statistically significant difference in re-infection or treatment failure between doxycycline and azithromycin, but more patients who received azithromycin experienced re-infection/treatment failure compared to doxycycline. Antibiotic selection for treatment of Chlamydia infection should continue to be based on 2021 CDC STI Guideline recommendations with doxycycline as the agent of choice. Creation of the order panel was beneficial in minimizing double coverage and allowed for better treatment administration.

Title: Carbapenem Stewardship: Reducing Overuse in Empiric Treatment Strategies

Authors: Reshma Patel, Kristina Nakhla, Michael Saxon, Melissa Letzin 

Objective: This study aims to retrospectively evaluate carbapenem utilization across Northside Hospital’s five campuses to assess adherence to current Northside Hospital defined criteria, refine prescribing practices and reduce carbapenem overutilization.

Background: Carbapenems, a broad-spectrum class of antibiotics, are often overutilized in inpatient settings. While carbapenems are effective as a primary treatment option for infections caused by extended spectrum β-lactamase (ESBL)-producing bacteria, their overuse has raised concerns about developing carbapenem-resistant organisms. Establishing and adhering to appropriate carbapenem prescribing criteria is necessary to support effective stewardship.

Methods: This multi-center, randomized, retrospective chart review included patients 18 years or older, admitted to the inpatient medical-surgical floor at Northside Hospital campuses and received more than one dose of empiric carbapenem therapy from July 2023 through July 2024. Patients who received a single carbapenem dose in the emergency department, admitted to the intensive care unit (ICU), or on bone marrow transplant (BMT) service were excluded. The primary objective was to assess the appropriateness of carbapenem therapy based on current Northside Hospital defined criteria. Secondary objectives included evaluating average days of therapy for carbapenems, average days of therapy for total antibiotics, percentage of patients with confirmed ESBL isolates, and percentage of patients with confirmed multi-drug-resistant organism (MDRO) infections. 

Results: The retrospective review of 150 eligible patients indicated significant overutilization of carbapenems across all Northside Hospital campuses. The study population consisted of 57% (86/150) females and 43% (64/150) males. Only 48% (72/150) of patients met the appropriate criteria for carbapenem therapy. 52% (78/150) of patients did not meet the appropriate criteria for carbapenem therapy. The most commonly treated infections in the patients that met appropriate criteria for carbapenem prescribing were urinary tract infections (35%), intra-abdominal infections (24%), empiric coverage for sepsis (11%). The most commonly treated infections in the patients that did not meet appropriate criteria for carbapenem prescribing were urinary tract infections (36%), intra-abdominal infections (35%), and bacteremia (25%). The average duration of carbapenem therapy was 6.5 days, while the average duration for total antibiotic therapy was 7.6 days in patients with confirmed ESBL/MDRO infections. The average duration of carbapenem therapy was 5.8 days, while the average duration for total antibiotic therapy was 7.9 days in patients with no ESBL/MDRO infection or negative culture. Confirmed ESBL isolates were identified in 6% (9/150) of patients. Confirmed MDRO were identified in 5% (7/150).

Conclusion: This study highlights overutilization of carbapenem therapy across Northside Hospital campuses outside of the ICU, BMT service and single doses in the emergency department. With 48% of patients meeting appropriate criteria for its use, the findings suggest opportunities to optimize prescribing practices when initiating antimicrobial therapy. A majority of carbapenems were ordered without meeting clinical indications. Implementing standardized protocols and reinforcing antimicrobial stewardship across all campuses could enhance the appropriate use of carbapenems while reducing the risk of resistance and improving patient outcomes.

Title: Incidence of AKI Before and After Implementation of a Pharmacy-Driven Intravenous Acyclovir Protocol 

Authors: Eryn Meegan, Will Anderson, Dustin Ziegler, Kishan Patel

Objective: To assess the occurrence of AKI rates before and after implementing a pharmacy-driven intravenous acyclovir protocol aimed at optimizing dosing and intravenous hydration

Self-Assessment Question: True or False - Pharmacy involvement resulted in increased IV fluids ordered alongside IV acyclovir

Background: Acyclovir, a nucleoside analogue antiviral, is a well-recognized cause of drug-induced acute kidney injury (AKI) through crystal nephropathy, which results from intratubular obstruction due to crystalline precipitation in distal tubular lumens. In order to mitigate the risk of acyclovir-induced nephrotoxicity, the Cone Health Pharmacy and Therapeutics Committee approved and implemented a pharmacy-driven intravenous acyclovir protocol in May 2022. With this protocol, the pharmacy team aimed to improve patient safety by providing tailored dosing recommendations and ensuring appropriate fluid administration. The purpose of this study was to evaluate the effect of implementing this pharmacy-driven protocol on AKI rates. 

Methods: This institutional review board-approved, retrospective cohort study evaluated the implementation of a pharmacy-driven protocol to reduce the risk of AKIs in patients on intravenous acyclovir. This study was conducted within Cone Health, a single hospital system, between April 2020 to August 2024. Patients were included if they were 18 years or older and received at least 24 hours of intravenous acyclovir within the pre-consult implementation period of April 2020 to April 2022 or the post-consult implementation period of August 2022 to August 2024. Patients were excluded if they had end-stage renal disease, presented with an AKI, if baseline renal function was unknown, or if serum creatinine was not trended throughout the duration of acyclovir treatment. The primary endpoint was the incidence of AKI as defined by the 2012 KDIGO guidelines: an increase in serum creatinine by greater than or equal to 0.3 mg/dL within 48 hours, or an increase in serum creatinine to greater than or equal to 1.5 times baseline within the prior 7 days. The secondary endpoint evaluates the protocol's effectiveness in preventing AKI by assessing duration of intravenous fluid administration ordered per protocol. Fisher's exact test and descriptive statistics were used to analyze the data as appropriate.  

Results: Of the 120 patient charts reviewed, 31 met inclusion criteria (11 in the pre-implementation period and 20 in the post-implementation period). Baseline characteristics were similar between the two groups. Notably, more patients in the post-implementation group were on concomitant nephrotoxic agents compared to the pre-implementation group (13 patients vs. 8 patients). Median duration of acyclovir therapy increased from 2.4 days (IQR 1.7–4.0) in the pre-implementation group to 3.3 days (IQR 2.5–4.9) in the post-implementation group. The rate of AKI was 18% before implementation and increased to 25% after implementation, though this difference did not reach statistical significance (P = 0.38). Intravenous fluids were ordered for all patients (100%) compared to 82% pre-implementation, though this difference was not statistically significant (P = 0.12). The median duration of IV fluid administration significantly increased from 0.8 days (IQR 0.3–2.4) to 3.5 days (IQR 2.9–6.4) post-implementation (P = 0.0006). The rate of appropriate acyclovir dosing remained consistent between groups (91% vs 90%, P = 0.93). Similarly, the frequency of under-dosing was low and comparable (9% vs 10%, P = 0.99), and no patients in either group were over-dosed.

Conclusion: Implementation of a pharmacy-driven intravenous acyclovir protocol led to a significant increase in the duration of IV fluid administration. While the incidence of AKI was numerically higher in the post-implementation group, this difference was not statistically significant. Dosing accuracy remained high across both groups, with minimal under-dosing and no cases of overdosing observed. These findings suggest that the protocol successfully enhanced supportive care practices without compromising dosing safety, though further evaluation in a larger cohort may be warranted to better assess its impact on AKI prevention.

Title: Impact of Guideline Implementation on Management of Long Bone Osteomyelitis

Authors: Melat Endashaw, Jessica Howard-Anderson, Jesse Jacob, Trinh Vu, K. Ashley Jones

Purpose: This study aims to evaluate the impact of a standardized approach to managing osteomyelitis of long bones and foot on hospital length of stay, readmission rates, and antibiotic-related adverse events. The results of this study may support novel strategies for the treatment of complex bone infections.

Background: Standard treatment for osteomyelitis, including diabetic foot osteomyelitis (DFO), usually requires surgical intervention followed by prolonged courses of intravenous (IV) antimicrobials. Emerging evidence suggests that oral antimicrobials can effectively treat complex bone and joint infections, offering similar therapeutic outcomes while reducing cost and complications. The 2019 Oral Versus Intravenous Antibiotics (OVIVA) Trial demonstrated these findings, prompting changes in clinical practices at various institutions. Recently, the Infectious Diseases Society of America (IDSA) and International Working Group on the Diabetic Foot (IWGDF) published a guideline recommending oral therapies as acceptable treatments for patients with DFO and shorter treatment durations in certain cases. In August 2023, Emory University Hospital Midtown, an academic medical center in Atlanta, Georgia, implemented institutional guidance on osteomyelitis of long bones and foot, including DFO, that created OVIVA and IWGDF informed, standardized recommendations on the selection of empiric and pathogen-directed therapies with a focus on minimizing the need for IV antimicrobials and outpatient parenteral antimicrobial therapy (OPAT), while promoting oral therapy for stable patients after adequate source control. It also addresses the importance of multidisciplinary involvement to provide a clear framework for managing osteomyelitis of long bones and DFO, with the goal of streamlining and optimizing care for these patients.  

Methods: This is a single-center, retrospective study evaluates adult patients diagnosed with osteomyelitis of long bones, including DFO, who received antibiotic treatment. The study population were evaluated in two groups: patients treated prior to guideline implementation from October 1, 2022 to March 31, 2023 and patients treated after guideline implementation from February 1, 2024 to July 31, 2024. Exclusion criteria included patients with implanted hardware at the infection site, septic arthritis or native vertebral osteomyelitis, necrotizing or non-bacterial infection, blood cultures positive for Staphylococcus aureus or Staphylococcus lugdunensis, or concurrent invasive infection without sufficient evidence for use of oral antimicrobials (e.g., endocarditis, meningitis). Patients who underwent curative amputation without further intent to treat with antibiotics for osteomyelitis were also excluded. The primary outcome was hospital length of stay. Secondary outcomes include rates of readmission and antibiotic-related adverse events. Statistical analysis used rank-sum and chi-squared tests, with an alpha of 0.05 to determine statistical significance.

Results: Of the 545 patient charts reviewed, 98 met inclusion criteria (45 pre-implementation group and 53 post-implementation). Baseline characteristics were similar between groups. Notably, more patients were discharged on oral therapy in the post-implementation group compared to pre-implementation (64.2% vs. 53.3%, p=0.28). Median length of stay was similar in the pre- and post-implementation groups (13 days vs. 12 days; p=0.26). Readmission rates (37.3% vs. 48.8%, p=0.26) and antibiotic-related adverse events (25.5% vs. 37.2%, p=0.23) were lower post-implementation though not statistically significant.

Conclusion: The implementation of institutional guidance for the treatment of long bone osteomyelitis, including DFO, may improve patient outcomes such as hospital length of stay, readmission rates, and complications, though our study was limited with a small sample size.

Contact: melat.endashaw@emoryhealthcare.org

Title: Real World Comparison of Intravenous versus Oral Antimicrobial Therapy for Bone and Joint Infections
Authors: Maura Kreiser, Sarah Al Mansi, Ismael Yunusa, Caroline Derrick, P. Brandon Bookstaver, Majdi N. Al-Hasan, Yorika Hammett, Morgan Pizzuti
Background: Outpatient Parenteral Antimicrobial Therapy (OPAT) has expanded significantly over the past few decades, driven by its clinical efficacy and cost-effectiveness. A landmark study in this field, the OVIVA trial (Oral versus Intravenous Antibiotics for Bone and Joint Infection), demonstrated the non-inferiority of oral antimicrobials compared to intravenous (IV) therapy for treating bone and joint infections. However, OVIVA was conducted before the widespread use of certain long-acting injectables or highly bioavailable antimicrobials, such as dalbavancin and linezolid, respectively, which are now commonly used for prolonged treatment durations. Since OVIVA, there has been increased comfort with prescribing oral antimicrobials for bone and joint infections, yet real-world prescribing patterns and outcomes remain understudied. This study aims to evaluate local, real-world use of IV versus oral antimicrobials in bone and joint infections and assess treatment and logistic failure rates.
Methods: This retrospective cohort study included adult patients with a bone and/or joint infection admitted to and discharged from one of four study locations. Patients were eligible if they had an infectious diseases consultation between January 2023 and August 2024 that outlined at least 4 weeks of planned antimicrobial therapy. The primary outcome was treatment failure within one year of active antimicrobial treatment, defined as provider-determined treatment failure, microbiologic recurrence, hospital readmission, radiologic or operative evidence of persistent or worsening infection, mortality, or antimicrobial changes due to adverse events or intolerance. Secondary outcomes included logistic failure rates and risk factors for treatment and logistic failure. The primary outcome was assessed using Cox regression, while secondary outcomes were analyzed using both descriptive statistics and logistic regression.
Results: In Progress
Conclusions: In Progress

Title: Functional Cure of Hepatitis B Infections Among Patients Co-infected with HIV on Tenofovir-based Antiretroviral Therapy
Authors: Adesuwa Utomwen, Emily Steinbock, Minh Pham
Site: Cone Health – Moses H. Cone Memorial Hospital; Greensboro, NC

Objective: Define functional cure of HBV infections and identify the ideal guideline-directed treatment regimen used for HIV and HBV coinfected patients

Background:
Human immunodeficiency virus (HIV) affects approximately 1.2 million people in the United States, and among these patients, it is estimated that 10% are coinfected with chronic hepatitis B viral (HBV) infection. In patients with HBV, functional cure, defined by loss of hepatitis B surface antigen (HBsAg), is rare. Only 2-4% of HBV mono-infected patients receiving treatment achieve functional cure. Some studies have suggested that patients co-infected with HIV and HBV achieve higher rates of functional cure, approximately 7-10%, likely due to lifelong exposure to antiretroviral therapy (ART).  ART regimens containing tenofovir are the most widely recommended treatment for HBV co-infected patients. Patients achieving functional cure should be re-vaccinated to help stimulate the production of hepatitis B antibodies (anti-HBs). The primary objective of this study was to determine the incidence rate of functional cure among patients coinfected with HIV/HBV who were taking a tenofovir-based ART regimen.

Methods:                                                                                                         
This study was a single-centered, prospective, IRB-approved, interventional study evaluating the incidence of HBsAg loss among HIV/HBV co-infected patients over a 7-month period from August 1, 2024 to February 28, 2025. The study population was identified using a report that included patients with confirmed diagnoses of both HIV and Hepatitis B at the Cone Health Regional Center for Infectious Diseases clinic. Patients were included if they were 18 years of age or older, had confirmed HIV and HBV diagnoses, and were currently receiving care at the RCID clinic. Patients were excluded if they were lost to follow-up at the RCID clinic, diagnosed with hepatitis C viral infection, not receiving treatment with a tenofovir-containing therapy regimen, or were currently involved in another research study. For patients meeting the inclusion criteria, the researcher scheduled HBsAg labs to be collected during patients’ future appointments, notified providers of these orders, and determined the need for vaccinations based on the laboratory results.  The primary outcome was the incidence of functional cure of hepatitis B. The secondary outcome reviewed lab collection patterns. Subgroup analyses involved a comprehensive description of patients meeting the primary objective.

Results:
A total of 37 patients were included in this study. Two (5.4%) patients achieved functional cure of HBV after being treated with long-term ART (Biktarvy) for more than 2 years (95% CI 0.7-18.2). Out of the 37 enrolled patients, labs were only ordered for 31 because the remaining appointments were outside of the study time period. Ultimately, labs were collected for 12 (74%) of appointments due to logistical reasons. None of the patients who achieved functional cure of HBV were eligible for HBV re-vaccination due to the production of anti-HBs at the time of cure. Thus, both patients seroconverted without requiring the HBV vaccine. One patient with functional cure of HBV developed an anti-HB level of 10, indicating complete protection against HBV. It is uncertain if the remaining cured patient achieved full immunity because the appropriate quantitative anti-HB lab was not ordered.

Conclusion:
The incidence of functional cure amongst patients co-infected with HIV and HBV was lower than previously reported rates in the literature, which is likely due to our small sample size and high exclusion rate. Our results add new local evidence about the incidence of functional cure of hepatitis B in patients coinfected with HIV and validate the need for universal HBV therapy in this population.  Practice changing recommendations that can be gathered from this study includes implementing a new standardized workflow protocol for coinfected patients to encourage laboratory stewardship, providing additional guidance that will assist practitioners with medication management decisions for specific clinical scenarios (i.e. requiring immunosuppressive therapy) and creating opportunities to involve current on-site RCID pharmacists into this new workflow. Further local studies are needed, however, to determine the most accurate incidence of hepatitis B functional cure rates within this region and to evaluate the most appropriate means of properly monitoring this unique patient population.

Title: Impact of an Antimicrobial Stewardship Bundle on the Treatment of Urinary Tract Infections in Older Adults
Authors: Elly R. Sherman, PharmD; Maria Muehrcke, PharmD, MBA, BCPS; Laura Bobbitt, PharmD, BCIDP
Objective: To assess how antimicrobial prescribing changed after the implementation of a geriatrics-specific antimicrobial stewardship bundle
Background: Urinary tract infections (UTIs) are a common indication for hospital admission in geriatric patients. However, these infections are often misdiagnosed, especially in patients with altered mental status. The risks of overtreating UTIs include the development of antimicrobial resistance and adverse drug effects, including C. difficile colitis. Many institutions, including Vanderbilt University Hospital (VUH), have implemented antimicrobial stewardship initiatives in response to these risks. This retrospective, single-center analysis aims to assess how antimicrobial prescribing changed after the implementation of a geriatrics-specific antimicrobial stewardship bundle at VUH. 
Methods: Included patients were ≥65 years of age, admitted to the geriatrics teaching service, and had a urinalysis ordered during admission. Patients with a neurogenic bladder, altered urologic anatomy, concomitant infection, who were receiving antibiotics immediately prior to admission, were neutropenic, or transitioned to comfort care within 48 hours of admission were excluded. The primary outcome was days of antimicrobial therapy per 1000 patient days. Secondary outcomes included rates of discontinuation of antibiotic therapy in asymptomatic bacteriuria, duration of therapy, rates of C. difficile colitis within 90 days, and proportion of patients with an inappropriate UTI diagnosis.
Results: In progress
Conclusions: In progress

Title: Clinical Outcomes in Patients who Receive Ertapenem vs. Meropenem for Extended Spectrum Beta-Lactamase Infections and Have Hypoalbuminemia

Authors: Kendall Ferrara, Melissa George, Joshua Rumph

Background: There are limited and conflicting data currently available for the treatment of ESBL infections in patients with hypoalbuminemia. The standard approach for patients with ESBL infections is treatment with a carbapenem. Ertapenem, compared to other carbapenems, is highly protein bound. In patients that are hypoalbuminemic and/or critically ill, this leads to an increased free fraction of ertapenem and a significantly decreased half-life. Limited clinical literature has shown a significantly increased risk of mortality, readmission, and length of stay in patients who are hypoalbuminemic and receive ertapenem compared to patients receiving other carbapenems. Based on this data, the Infectious Diseases Society of America (IDSA) Antimicrobial-Resistant (AMR) Guidance document suggests utilizing meropenem or imipenem-cilastatin in patients that are critically ill and/or experiencing hypoalbuminemia for ESBL infections outside of the urinary tract. Historically at East Carolina University (ECU) Health, ertapenem has been more commonly used than meropenem for ESBL infections regardless of clinical status or albumin. This study aims to evaluate the treatment failure of ertapenem compared to meropenem in patients who have ESBL infections and hypoalbuminemia. 

Methods: This was a system-wide, retrospective chart review of hospitalized adult patients at ECU Health with hypoalbuminemia who received ertapenem or meropenem for at least 72 hours and had non-urine cultures positive for ESBL Enterobacterales. Hypoalbuminemia was defined as an albumin ≤2.5 g/dL within 72 hours before or after initiation of antibiotic treatment. SlicerDicer in EPIC and the electronic medical record (EHR) were utilized to identify patients. The primary endpoint was treatment failure defined as a composite of 30-day all-cause mortality and infection related readmission. Secondary outcomes included the individual components of the composite outcome, 90-day all-cause mortality and infection related readmission, and hospital length of stay (LOS). Subanalyses of patients with bacteremia and patients admitted to an intensive care unit (ICU) were also performed.

Results: A total of 156 patients with ESBL infections and hypoalbuminemia were included in the study. Of those included, 104 (66.7%) received ertapenem and 52 (33.3%) received meropenem. Overall, baseline characteristics were similar between groups. There was a statistically significant difference in age (70 vs 63 years old) and weight (78.1 vs 90.6 kg), however, these differences are not clinically significant and the difference in weight may be attributed to our institution’s previous rapid molecular blood culture protocol recommending meropenem in patients with a BMI ≥35 kg/m2. Although patients in the meropenem group had significantly lower albumin levels (2.1 g/dL vs 2.3 g/dL, p = 0.0131), this was not clinically significant. The most common type of culture in both groups was blood (57.7% vs 44.2%). Wound cultures were the second most common (18.3% vs 28.8%). ESBL Escherichia coli was the most frequently isolated organism in both groups (54.8% vs 40.4%). There was no statistically significant difference in the primary outcome of treatment failure between the ertapenem and meropenem groups (34.6% vs 46.2%, p = 0.1682; RR 0.75, 95% CI 0.505-1.113). Secondary outcomes, including 30- and 90-day all-cause mortality and infection-related readmission, also showed no significant differences. Subgroup analyses (ICU, age ≥65, bacteremia) revealed no significant differences but were limited by small sample sizes.

Conclusion: In patients with ESBL infections and hypoalbuminemia, there was no significant difference in treatment failure between ertapenem and meropenem. Although numerical differences favored ertapenem, the study was underpowered to detect a statistical significance. Larger, prospective studies are needed to confirm these findings. 

Contact: Kendall.Ferrara@ecuhealth.org