2025 Southeastern Residency Conference

Title: Effectiveness and safety of high-dose unfractionated heparin for venous thromboembolism prophylaxis in obese patients
Authors: Amber DeVillier, Lacey Ioppolo, Mallory Stringer, Eric Shaw

1. Background: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a preventable condition causing 60,000 to 100,000 deaths annually in the United States. DVT involves thrombus formation in extremities, while PE occurs when a thrombus blocks a pulmonary artery. Risk factors include Virchow’s triad which consists of venous stasis, endothelial injury, and hypercoagulability. Obesity, an independent VTE risk factor, promotes inflammation, impaired fibrinolysis, and procoagulant activity. The CDC defines obesity as a BMI ≥ 30 kg/m². Hospitalized patients face increased VTE risk due to immobility and surgical endothelial injury. Chemical prophylaxis, such as unfractionated heparin (UFH), low molecular weight heparin (LMWH), or fondaparinux, is essential. Standard dosing of UFH is 5,000 units subcutaneously every 8 hours. In patients with an increased BMI the dosing parameters are not as clear. The dosing for DVT prophylaxis in patients with obesity ranges from 5,000 to 7,500 units subcutaneously every 8 hours. Studies on high-dose UFH of 7,500 mg subcutaneously every 8 hours in obese patients show mixed outcomes, with potential bleeding risks in class III obesity (BMI ≥ 40 kg/m²). Further research is needed to clarify optimal dosing regimens by BMI and assess safety and efficacy.
2. Methods: This was a single-center, retrospective chart review of patients that were started on either standard-dose UFH of 5,000 mg subcutaneously every 8 hours or high-dose UFH of 7,500 mg subcutaneously every 8 hours for DVT prophylaxis between January 2018 and September 2024. Patients were included if they were 18 years old or older, received either standard-dose or high-dose UFH within 48 hours of admission, and if their BMI was ≥ 40 kg/m² and body weight ≥ 120 kg. The primary outcome was incidence of new VTE during hospital stay. The secondary outcomes included any bleeding that resulted in discontinuation and a composite of ISTH major bleeding.
3. Results: A total of 352 patients were screened, with 108 patients included in this study. There were 83 patients in the standard-dose UFH group and 25 in the high-dose UFH group. The primary outcome was not statistically different between standard-dose compared to high-dose (2.4% vs 0%; p-value 1.000). The secondary outcome of composite ISTH major bleeding was also not significantly different between standard-dose and high-dose (18.1% vs 32%; p-value 0.252). When looking at individual components of ISTH major bleeding, there were significantly more rates of blood transfusions in the high-dose group compared to the standard-dose group (12% vs 1.2%; p-value 0.038). The secondary outcome of UFH prophylaxis discontinuation due to bleeding occurred in 2 (1.9%) of patients in standard-dose group and none of the patients in the high-dose group.
4. Conclusions: This study showed that there was no difference in the incidence of new VTE between high-dose and standard-dose UFH, but notably, high-dose UFH was associated with more blood transfusions.

Contact Amber DeVillier (amber.devillier@hcahealthcare.com) with any questions.

Title: Major Risk Factors Associated with the Development of Candidemia in Intensive Care Units at University Hospital in Mobile, AL 
 
Authors: Kennadi Johnson, Ashley Hawthorne, Callie Seales
 
Background: Data on candidemia in the United States are limited. The Centers for Disease Control and Prevention (CDC) reports that approximately 25,000 cases of candidemia occur annually with a mortality rate of 25%. Due to its opportunistic nature, candidemia is primarily seen in critically ill and immunocompromised patients. Common risk factors include immunosuppression, current Candida colonization, central venous catheter placement, recent abdominal surgery, and broad-spectrum antibiotic use, to name a few. The “Candida score” was developed in 2009 and may be utilized as a predictor of invasive Candida infection; however, it has numerous limitations. The Infectious Diseases Society of America (IDSA) 2016 Clinical Practice Guideline for Management of Candidiasis recommends initiating empiric antifungal therapy in select critically ill, non-neutropenic patients.
 
Methods: In this retrospective, single-site study, patients were identified via a report in the medical record to capture all patients ≥ 18 years of age in the Intensive Care Units (ICU) with Candida in ≥ 1 blood culture(s). Patients not admitted to the ICU or with neutropenia were excluded. The following data was collected: age, gender, race, date and ward of admission, length of stay, collection date of first positive Candida blood culture, vital signs and labs at ICU admission and within 72-hours of positive Candida blood culture, past medical history, time of intubation and extubation, in-hospital mortality, and empiric antifungal therapy. Pre-disposing factors including pacemaker or defibrillator placement, any mode of dialysis, central venous catheter (CVC), foley catheter, total parental nutrition (TPN) use, home medications, history of intravenous (IV) drug use, presence of multifocal Candida colonization, and recent abdominal surgery were also collected. The primary objective of this study is to identify risk factors associated with the development of candidemia in ICU at our institution. The secondary objectives are to evaluate the performance of the “Candida score”, in-hospital mortality, incidence of candidemia by ICU location, and frequency of empiric antifungal therapy. Descriptive statistics were utilized to describe the results, and the “Candida score” was calculated for each patient.      
 
Results: Between October 1, 2018, and July 1, 2024, thirty-five patients met the inclusion criteria. The pre-disposing factors occurring in ≥ 50% of the study population were CVC (n=32, 19%), foley catheter (n=30, 86%), mechanical ventilation (n=29, 83%), and severe sepsis (n=20, 57%). Candida albicans was the most common species isolated (n=15, 43%). The percentages of patients admitted to the medical intensive care unit (MICU), surgical-trauma intensive care unit (STICU), and neuroscience intensive care unit (NSICU) were 49% (n=17), 46% (n=16), and 6% (n=2), respectively. In-hospital mortality occurred 63% (n=22) of the sample. The “Candida score” was only positive for 40% (n=14) of the sample, and 46% (n=16) of patients received empiric antifungal treatment.      
 
Conclusion: In this analysis, CVCs, foley catheters, severe sepsis, and mechanical ventilation were the most common characteristics amongst patients who developed candidemia. Lastly, the “Candida score” failed to accurately predict the likelihood of developing in candidemia in non-neutropenic, critically ill patients at University Hospital in Mobile, AL.

APIXABAN SAFETY AND EFFICACY FOR THE TREATMENT OF VENOUS THROMBOEMBOLISM IN PATIENTS ON DIALYSIS 
L. Ashton Dickinson, TJ Hodge, Robert Moye, Kimberly Keller, Abby Cowan, Taylor Bird, Ross M. Nesbit 
University of Tennessee Medical Center – Knoxville, TN 
 
Background/Purpose: While there is data in favor of using apixaban for the treatment of acute venous thromboembolism (VTE) in patients with End Stage Renal Disease (ESRD), more data is needed to inform safe and efficacious dosing in this population. This study evaluated the safety and efficacy outcomes of various apixaban dosing strategies for acute VTE in adult hospitalized patients with ESRD on dialysis.    
Methodology: This was a single-center, retrospective analysis that drew data from dialysis patients who experienced an acute VTE between the period of January 2016 and December 2023. Groups compared included patients who received apixaban 10 mg BID for 7 days (full lead-in dosing) with 5 mg BID thereafter to patients who received apixaban 10 mg BID for 0-6 days (modified lead-in dosing) with 5 mg BID thereafter. Patients > 18 years with ESRD on maintenance dialysis (hemodialysis or peritoneal) and a newly diagnosed acute VTE receiving anticoagulation therapy with apixaban were included in this study. Primary endpoints collected comprised of&n

Title: The Clinical Puzzle of Anaerobic Bacteremia: Unpacking Traits of Infections and Patients with Anaerobic Bloodstream Infections and Impact of Adequate Treatment 
Authors: Sonjala Mallory, James Holland, Tyler Martin, Geren Thomas 


Background: Anaerobic bloodstream infections (BSIs) are rare but clinically significant, with mortality rates ranging from 15% to 55%. These infections are commonly associated with immunosuppression, malignancies, and surgical interventions. The most frequent causative pathogens include Bacteroides spp., Clostridium spp., and Fusobacterium spp., with increasing resistance complicating treatment. Distinguishing true infections from contaminants, particularly Cutibacterium spp., remains a diagnostic challenge. This study aims to characterize anaerobic BSIs, identify factors distinguishing true infections from contamination, and assess the impact of timely and appropriate antibiotic therapy on patient outcomes.


Methods: This retrospective, cross-sectional study was conducted at a teaching hospital from January 2019 to April 2024. Sixty patients with confirmed anaerobic bloodstream infections were included. Patient demographics, source of infection, and clinical severity (PITT Bacteremia Score) were collected. Microbiological data, including blood culture results, were used to determine antibiotic adequacy. Patients were divided into two groups based on whether they received adequate or inadequate antibiotic therapy. Outcomes of interest include infection resolution, length of hospital stay, and 30-day all-cause in-hospital mortality. The correlation between appropriate indication documentation and antibiotic selection was evaluated. Descriptive statistics were used to summarize characteristics, and correlations between treatment adequacy, documentation, and outcomes were explored.


Results: In-Progress


Conclusion: In-Progress

Title: Impact of a Pharmacist-Led Glycemic Management Consult Service in Hospitalized Patients  


Authors: Dion Blocker, Michelle Marbury, Mariam Agbe


Background: Diabetes is a major chronic health problem, and its prevalence continues to grow nationwide. If left uncontrolled, patients may develop microvascular and macrovascular complications, which can lead to morbidity, mortality, and decreased health-related quality of life. Wellstar Cobb Medical Center is the only hospital in the Wellstar Health System with a pharmacist-led glycemic management consult service. The clinical pharmacy team manages patients admitted to the hospital and makes a vast number of interventions. Based on the lack of evidence regarding pharmacist-led glycemic management, this study aims to evaluate the safety and efficacy of pharmacy-managed basal-bolus regimens in hospitalized patients. 


Methods: The design of the study is a single-center, retrospective, noninferiority chart review of adult patients admitted to Wellstar Cobb Medical Center. A drug utilization report will be used to identify hospitalized adults who received insulin therapy at Wellstar Cobb Medical Center from January 2018 to July 2024. A maximum of 500 patients will be randomized and included from each treatment group. This study aims to examine the incidence of hypoglycemic events with a pharmacist-led glycemic-monitoring protocol compared to usual care. This study will compare the time to euglycemia after the first abnormal glycemic level, average incidence of hypoglycemic events, total length of stay, continued hyperglycemia after initial regimen, and hospital readmission within 30 days. Data will be obtained from Enterprise Data Analytics due to data query limitations identified in Epic Slicer Dicer. Adult patients with a past medical history of diabetes who are admitted with a blood glucose level greater than 140 mg/dL on basal, bolus, or continuous insulin will be included in the study. Patients using only sliding scale insulin, experiencing critically ill COVID-induced hyperglycemia, with concurrent insulin pump therapy, on hospice, or with consecutive readings of blood glucose 110-180 mg/dL with no more than two BG readings outside the range within 48 hours of admission without a pharmacy to dose basal bolus consult will be excluded from the study. 


Results: The study analyzed 100 hospitalized adult patients divided into two groups: those managed by pharmacist-led glycemic consultation (n=50) and those managed by usual care without pharmacist consultation (n=50). Although not statistically significant, patients receiving pharmacist consultation achieved euglycemia faster (60.7 ± 49.9 hours) compared to the usual care group (93.2 ± 108.6 hours, p=0.05). Additionally, a significantly greater proportion of patients reached euglycemia in the pharmacist consultation group (82%) compared to the control group (50%, p=0.0007). The pharmacist consultation group experienced fewer cases of continued hyperglycemia 72 hours after insulin initiation (38% vs. 66%, p=0.005), which was statistically significant. Length of stay and hypoglycemic events did not significantly differ between groups.

Conclusion: Although not statistically significant, the pharmacist-led glycemic management consult service was associated with improved time to achieve euglycemia in hospitalized patients compared to usual care. Although there was no statistically significant difference in time to euglycemia, hypoglycemic events or length of hospital stay, pharmacist-managed care effectively achieved statistically significant effects on persistent hyperglycemia and achieving euglycemia. These findings support the integration of pharmacist services into hospital glycemic management protocols.

Title: Vasopressor-Sparing Effects of Methylene Blue versus Hydroxocobalamin for Vasoplegic Syndrome Post-Cardiac Surgery

Authors: Cameron Garramone, Reena Patel, Michael Byers, Deidra Garrett

Objective: Compare vasopressor-sparing effects calculated using the vasoactive-inotropic score (VIS) after the administration of methylene blue or hydroxocobalamin for vasoplegic syndrome (VS) post-cardiac surgery.

Self-Assessment Question: What is the difference between methylene blue and hydroxocobalamin in vasopressor-sparing effects for vasoplegic syndrome post-cardiac surgery?

Background: VS is a life-threatening condition that occurs in 5% to 25% of patients undergoing cardiac surgery using cardiopulmonary bypass (CBP) with a mortality rate as high as 25%. The mainstay of managing VS is catecholamine vasopressors, such as epinephrine and norepinephrine. For VS refractory to vasopressors, second-line therapies such as methylene blue and hydroxocobalamin play a key role in its management. Several studies evaluated the use of these therapies and showed a significant decrease in vasopressor requirements and improvement in hemodynamic parameters. At Piedmont Atlanta Hospital, methylene blue is the initial choice for treating refractory VS unless contraindications, such as concomitant use of serotonergic drugs or those with glucose-6-phoshate dehydrogenase (G6PD) deficiency, are present. The VIS calculation, a commonly used tool in research settings, was utilized to objectively quantify the degree of vasopressor support required to maintain hemodynamic stability. Further research is warranted given the lack of direct comparator studies for treating VS using this scoring tool.

Methodology: This was a retrospective chart review of adult patients who underwent cardiac surgery and received either methylene blue or hydroxocobalamin for the treatment of VS between January 2022 and August 2024. Types of cardiac surgery included coronary artery bypass graft, heart valve procedures, left ventricular assist device implant, and heart transplantation. Patients were excluded if interventions were administered > 24 hours post-cardiac surgery, supported on extracorporeal membrane oxygenation (ECMO) prior to surgery, or received tocilizumab intraoperatively. The primary outcome was percent change in VIS from baseline to 24 hours after methylene blue or hydroxocobalamin administration. Secondary outcomes included percent change in VIS from baseline to each timepoint (1, 2, 6, and 12 hours), percent change in mean arterial pressure (MAP) from baseline to 24 hours, need for additional VS treatment (methylene blue or hydroxocobalamin [if not used initially] and angiotensin II), need for ECMO 24 hours post-cardiac surgery, and number of vasopressors discontinued at 6 hours. Clinical outcomes included length of stay from time of procedure and hospital mortality at 24 hours. Statistical analysis was completed using Wilcoxon Rank Sum or independent t-test and chi-square or Fischer’s exact test where appropriate. A p-value of < 0.05 was considered statistically significant.

Results: In the assessed cohort, 35 patients from each group were included for analysis. When comparing methylene blue to hydroxocobalamin, there was a statistically significant difference noted in the primary outcome of percent change in VIS from baseline to 24 hours (-46.4% vs -64.8%; p=0.027), and percent change in MAP from baseline to 24 hours (12.3% vs 22.2%; p=0.012). No statistical significance was found in need for additional VS treatment (40% vs 25.7%; p=0.203), need for ECMO 24 hours post-cardiac surgery (5.7% vs 11.3%; p=0.238), or number of vasopressors discontinued at 6 hours (22.9% vs 22.9%; p=1). The use of hydroxocobalamin had a numerically higher incidence of 2 or more vasopressors being discontinued at 6 hours (37.5% vs 75%; p=0.137), but not statistically significant. There was a statistically significant difference for percent change in VIS from baseline to 12 hours (-29.4% vs -51.9%; p=0.04), but not at 1 hour (-2% vs -13.6%; p=0.153), 2 hours (-7.3% vs -22.6%; p=0.061), or 6 hours (-22.8% vs -28%; p=0.401).

Conclusions: There was a statistically significant difference noted in the primary outcome as well as the secondary outcomes of percent change in VIS from baseline to 12 hours and percent change in MAP from baseline to 24 hours. However, there were no major differences noted in any other secondary outcomes or clinical outcomes. Study limitations included the retrospective design, small patient population, and non-standardized vasopressor weaning protocol. Prospective trials with a larger sample size are warranted in this population.

TITLE: Justification of a Specialty Pharmacy Discharge Medication Reconciliation Program: 
A Descriptive Study 
Caroline Joncas, Taylor Wells 
 
BACKGROUND: Specialty pharmacies provide medications for patients living complex medical conditions including cancer, Human Immunodeficiency Virus, Multiple Sclerosis, and rheumatology conditions. These medications account for 55% of the United States medication expenditure. While previous literature has established the value of medication reconciliations at time of hospital discharge in patients on chronic medication therapy, minimal literature is available describing the impact on patients receiving medications from specialty pharmacies . The purpose of this study was to retrospectively identify opportunities for pharmacist interventions at time of discharge in patients receiving specialty medications and determine the type, severity, and cost savings associated with these interventions.   
 
METHODS:  This single-center retrospective descriptive study included patients with a documented fill history of a specialty medication at Cape Fear Valley Specialty Pharmacy for HIV or an oncologic disease state within 1 month of an inpatient admission between January 2022 and January 2024. Discharge summaries and specialty follow-up visit notes were reviewed for medication discrepancies. The primary endpoint was the number of opportunities for pharmacist intervention and associated cost avoidance, defined as number of errors found and the associated cost based on error severity. A validated scale was used to grade the severity of errors from no error to potentially lethal. 
 
RESULTS: A total of 90 patient encounters met inclusion criteria. Of these encounters, 76 (84%) were associated with cancer, 6 (7%) with HIV, and 8 (9%) with other diagnoses. Overall, 9 (10%) encounters had a medication error at time of hospital discharge. The majority of errors were identified as significant (78%), with one serious error and one potentially lethal error. The most common type of error was inappropriate omission (78%). The cost avoidance associated with these errors was $14,960 over the two-year study period.  
 
CONCLUSION: This study indicates that while some cost savings are possible through targeted medication reconciliations at time of discharge for specialty patients, the overall opportunity is not large enough to justify a medication reconciliation position specific to specialty pharmacy. However, this service would be a beneficial addition into the specialty pharmacy workflow, as there were significant cost savings considering the small number of issues identified by this study. 

Title: Assessing the Utility of Enoxaparin Anti-Xa Monitoring in Obesity for Venous Thromboembolism (VTE) 
Prophylaxis on Clinical Outcomes in the Hospital Setting 
Authors: Emilee Byrd, Angelica Marques, Ann Maxwell 
Background: Anti-Xa monitoring has been suggested to assess enoxaparin dosing in certain patient populations for the treatment of venous thromboembolism (VTE). However, there is no clear guidance on goal ranges for prophylactic enoxaparin and how this can affect the bleeding or clotting risk. Morbid obesity (BMI >40 kg/m2) is an important factor that can increase the risk of VTE. Some institutions have adopted anti-Xa monitoring in this patient population to guide prophylactic dosing. The purpose of this research study is to assess the use of anti-Xa monitoring for VTE prophylaxis using enoxaparin in obesity and its impact on clinical outcomes.   
Methods: This is a retrospective, observational single center cohort study evaluating morbidly obese patients admitted to McLeod Regional Medical Center that received prophylactic dosing of enoxaparin between August 1, 2023 and July 31, 2024. In order to be included in the study, patients needed to be 18 years or older, have a BMI >40 kg/m2, receive at least three doses of enoxaparin, and have at least one anti-Xa level collected. Patients with acute kidney injury (AKI) within the last seven days, pediatric patients, pregnant patients, orthopedic surgery patients, and trauma patients will be excluded.  The primary outcome is a composite of any VTE and any bleeding during hospitalization following prophylactic enoxaparin initiation. Secondary outcomes will include the individual components of the primary outcome (VTE, bleeding), number of repeat anti-Xa levels, percentage of anti-Xa levels in goal range and percentage of anti-Xa levels drawn within an appropriate time frame.  
Results: A total of 218 patients with a BMI >40 kg/m2 and receiving enoxaparin for VTE prophylaxis were reviewed. After applying the exclusion criteria, 81 patients were included in the study.  
The median age of patients included was 58 [IQR 44,70] with normal renal function and a median BMI of 50 [IQR 44,58]. Of the 81 patients included, 11% were also on concomitant NSAIDs and 40% of patients were receiving concomitant antiplatelet therapy with the most common being aspirin.  
For the primary composite outcome there were no incidences found of VTE and any bleeding in the 81 patients included in the study. 79% of the 81 anti-Xa levels collected were within the appropriate time frame with 59% of those levels being within the goal range. The incidence of sub-therapeutic levels that were collected within the appropriate time frame was 27% and 14% for supra-therapeutic levels. 
Conclusions:  Dose adjusting enoxaparin for VTE prophylaxis in morbidly obese patients does not appear to increase bleeding or VTE events. Anti-Xa monitoring can for VTE prophylaxis can lead to wasted resources when levels are drawn inappropriately and also lead to additional blood draws from the patient to obtain the level within the time frame. Based on the findings from this study, in patients with stable renal function receiving BMI dosing of enoxaparin it is reasonable to not check anti-Xa levels as this was not correlated with VTE or bleeding. Concomitant therapy with aspirin did not appear to increase the risk of bleeding.

TITLE: The Use of Direct Oral Anticoagulants in the Setting of Acute Kidney Injury and the Incidence of Bleeding   AUTHORS: Marion Javellana; Kyle Furlow; Nicole Metzger; Kayla Ann Phillips; Manila Gaddh; Ananth Vadde; Anna Crider; Amanda Van Prooyen; Carrie Callahan

OBJECTIVE: To determine if using direct oral anticoagulants (DOACs) in patients with acute kidney injury (AKI) increases bleeding events.

SELF ASSESSMENT QUESTION: Which of the following was the primary outcome measured in this study? A) Hospital length of stay (LOS) B) Major bleeding events C) 30-day all-cause readmissions

Title: Prothrombin complex concentrate in obese patients with factor Xa inhibitor-associated bleeding


Authors: Lam Ho, Alyssa Osmonson, John Michael Herndon, Jessica Starr


Objective: To evaluate the effectiveness of weight-based versus fixed-dose 4F-PCC for the reversal of factor Xa inhibitor-associated bleeding in obese patients 


Self-Assessment Question: Based on the result of this study, patient receiving weight-based regimen developed more thrombotic event?


Background: Many studies have demonstrated the effectiveness of 4F-PCC in reversing anticoagulation and managing bleeding associated with factor Xa inhibitors; however, there is a lack of data to guide optimal dosing in obese patients. Specifically, the role of fixed-dosing in this population requires further exploration. 


Methods: This a multicenter, retrospective cohort study conducted from January 2016 through April 2024. Electronic medical records of obese patients (BMI ≥30 kg/m²) receiving apixaban, rivaroxaban, or edoxaban who were treated with 4F-PCC were reviewed.  Patients were included if they were ≥18 years of age and had major bleeding associated with factor Xa inhibitors.  Major bleeding was defined as intracranial or critical-site hemorrhages, hemodynamic instability (SBP <90 mmHg, SBP drop >40 mmHg, HR >100 bpm), hemoglobin decrease >2 g/dL, or need for ≥2 PRBC units. Exclusion criteria included pregnant patients, and those transferred to an outside health system. The primary outcome is all-cause mortality. Secondary outcomes include hematoma expansion (≥6 mL or ≥33% increase), thromboembolic events, the need for a second 4F-PCC dose, and 48-hour transfusion requirements.


Results: Seventy-seven patients were included in the study. Mortality rates were 25% (n=12) in the fixed-dose group and 44.8% (n=13) in the weight-based group (p=0.0718). No thrombotic events were observed in either group. Two patients in the weight-based group required a second dose (p=0.0653). Transfusion within 48 hours was needed in 22.9% (n=11) of patients in the fixed-dose group and 20.1% (n=6) in the weight-based group (p=0.8194). Hematoma expansion occurred in one patient receiving weight-based dosing (p=0.5464).


Conclusions: This study found no difference in mortality between fixed-dose and weight-based dosing regimens. No thrombotic events were observed in either group. Larger studies are needed to evaluate the safety and efficacy of fixed-dose versus weight-based 4F-PCC for factor Xa inhibitors-associated bleeding in obese patients.