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: Monotherapy versus Combination Therapy in the Treatment of Enterococcus faecalis Bloodstream Infections
 
Authors: Amber D. Fraley, Daniel Anderson, Joshua Eudy
 
Objective: To evaluate the safety and efficacy of monotherapy and combination therapy for E. faecalis bloodstream infections.
 
Self Assessment Question: True or False: At this time, there is a need for more outcomes data for both monotherapy and combination therapy for E. faecalis BSI in the absence of IE.
 
Background: Enterococci are gram-positive facultative anaerobic organisms typically found as normal intestinal flora. The two most common species that cause infections in humans are E. faecalis and E. faecium. Historically, combination antibiotic therapy has been the standard of care in treating infective endocarditis (IE) caused by E. faecalis. However,  practice is occasionally extrapolated to E. faecalis bloodstream infections (BSI) without IE. With a lack of outcomes data to support use, combination therapy is a dogmatic practice based on in vitro data from the 1950s involving two antibiotics seldom used for E. faecalis infections, penicillin and streptomycin. 
Therefore, this study seeks to assess the safety and efficacy of monotherapy compared to combination therapy for E. faecalis BSI with or without IE.
 
Methods: This single-center, IRB-approved, propensity-matched, retrospective cohort study, conducted at Wellstar MCG Health, reviewed all adult patients hospitalized between January 1, 2017 and September 30, 2024 with at least one blood culture positive for E. faecalis. Patients were excluded from the study if they expired within 72 hours of index culture, had polymicrobial BSI, did not receive antibiotic treatment, and/or had a prior diagnosis of E. faecalis within the previous 60 days. The primary outcome was a composite of 30-day mortality, 60-day hospital readmission, and/or 60-day recurrence. Secondary outcomes were each individual component of the composite outcome, time to blood culture clearance, duration of bacteremia, length of hospital stay, and adverse events. Outcomes were evaluated using various statistical methods, including chi-squared and Mann-Whitney U, as appropriate. Demographics were evaluated using descriptive statistics. 
 
Results: Of the 139 patients who met the inclusion criteria, there was no statistically significant difference in the primary composite outcome for monotherapy compared to combination therapy (27.1% vs 27.8%; p=0.93), hospital length of stay (12.8 [8.1-24.8] vs​ 15 [8.6-23]; p=0.92), or​ adverse reactions (2.5% vs 5.6%; p=0.96).
 
Conclusion: Both monotherapy and combination therapy yielded similar outcomes for the primary composite and adverse reactions​, however, the study was not adequately powered to detect a difference. Therefore, at this time, larger studies are warranted comparing monotherapy and combination therapy for E. faecalis BSI with or without IE.
 
Contact Information: amber.fraley@wellstar.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 a 2,000mg Vancomycin Loading Dose Maximum in Adult Patients


Authors: Tori Parks, Sarah McDaniel, Ashley Lightfoot, Lauren Wright, Josh Settle


Background: Vancomycin is a tricyclic glycopeptide antibiotic that is used to treat gram positive infections including methicillin-resistant Staphylococcus aureus (MRSA) and ampicillin-resistant Enterococcus. Vancomycin has been associated with an increased risk of developing acute kidney injury (AKI). To try to combat this in our patients, the Baptist Health System utilizes both a vancomycin dosing protocol and InsightRx© software to dose and monitor vancomycin for antibiotic area under the curve (AUC) levels and toxicity. InsightRx© is a Bayesian dosing software that utilizes random vancomycin levels to compare individual patients to patients with similar baseline characteristics who have also been entered into the software. This allows InsightRx© to predict how patients will respond to different vancomycin dosing schedules and predict AUC levels, troughs, and toxicity levels. Previously, the Baptist Health System vancomycin dosing protocol allowed for a maximum of a 3000mg vancomycin loading dose.There was thought to be a trend upward in the amount of AKI cases that were being seen in patients who were receiving higher loading doses of vancomycin. For this reason, the protocol was updated in 2023 and went into effect in January of 2024 to reduce the maximum vancomycin loading dose to 2000mg. The objective of this study was to analyze the rates of AKI in patients who received more than a 2000mg vancomycin loading dose before the updated protocol compared to lower loading doses after the implementation of a 2000mg maximum vancomycin loading dose. 
 
 
Methods: This is a investigational review board exempt, retrospective chart review conducted within the Baptist Health system from September to December. All patients admitted to Baptist Medical Center South and Baptist Medical Center East who received vancomycin were identified through an electronic report. After Investigational Review Board (IRB) exemption, a retrospective chart review from September 2023 to December 2023 before the 2000mg loading dose maximum and from January 2024 to July 2024 after the loading dose maximum were evaluated through a chart review and through InsightRx©. Data collected on qualifying patients included demographics, laboratory data, medication administration record data.   


Results: A total of 50 pre-implementation and 50 post-implementation patients were reviewed. Average baseline serum creatinine was 1.36 mg/dL and 1.21 mg/dL respectively. Pre- 2000mg maximum, the rate of AKI was 18%. After the 2000mg maximum the rate of AKI was 10%. Patient receiving loading doses after the 2000mg mg loading dose maximum took longer to reach target AUC (400-600 ug/mL) than patients who received higher loading doses. The implementation of a reduced vancomycin loading dose maximum to 2000mg from 3000mg showed a slight decrease in the rates of AKI, however, these rates cannot be solely attributed to vancomycin loading doses. Reduction of the maximum vancomycin loading dose extended the time to reach therapeutic AUC levels but did not negatively impact clinical outcomes. More research is needed at a larger scale to determine if larger vancomycin loading doses are associated with higher rates of AKI.


Conclusion: The reduction of the vancomycin loading dose maximum to 2000mg decreased the incidence of AKI development by 8% though duration of vancomycin treatment increased by an average of 1.6 days, subsequently increasing the time to reach therapeutic AUC. This change in duration of therapy did not have a negative impact clinical outcomes. The concurrent administration of other nephrotoxic agents could have contributed to the AKI rate. Further research at a larger scale is needed to further analyze the effect of larger vancomycin loading doses on AKI development. Moving forward, the Baptist Health Vancomycin Dosing policy should be evaluated to considered increasing the maximum loading dose of vancomycin to 2500mg from the current 2000mg loading dose maximum.

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 Concomitant Antibiotic Use on Treatment Outcomes in Patients with Clostridioides difficile Infection Receiving Fidaxomicin.


Authors:Sonali Chikersal, Dahlia Kaiser, Jill Dunning
 
Background: 
Clinical studies have demonstrated increased clinical cure rates in patients receiving fidaxomicin compared to vancomycin with concomitant antibiotics (CAs). However, there is limited evidence on the impact of discontinuing or de-escalating CAs on patients receiving fidaxomicin. This study aims to provide insight on the impact of discontinuation or de-escalation of CAs on treatment outcomes for patients receiving fidaxomicin for CDI treatment. 


Methods: 
This retrospective cohort study was performed in a muti-site healthcare system from September 26th, 2022, to January 29th, 2025. Electronic medical records were reviewed to identify adult patients hospitalized within AdventHealth Central Florida Division with confirmed CDI and receiving CAs. Key inclusion criteria were age 18 years or older, positive Clostridioides difficile toxin test, and receiving one or more CAs for an infection other than CDI at the time of the fidaxomicin order. Key exclusion criteria were fulminant infection and patients who received IV metronidazole or oral vancomycin during the treatment period. Data was collected on patient demographics, comorbidities, antibiotic history, CDI severity markers, mortality, and hospital length of stay. The primary outcome was the rate of treatment success. Secondary outcomes include risk factors for treatment failure, in-hospital mortality, and hospital length of stay. 


Results: 
In this study, 56 patients met the inclusion criteria. Of this population, 28 (50%) were female, mean age was 67 years old, 8 (14.3%) had a prior episode of CDI, 6 (8.9%) had severe infection, and mean length of stay was 16.2 days. There was no significant difference for the treatment success outcome (100% vs 86.8%; P = 0.164) and mortality (0% vs 2.6%; P = 1.00) between the de-escalation/discontinuation group and CA group, respectively. The length of stay was significantly shorter in the de-escalation/discontinuation group compared to the CA group (6.5 days vs 14 days; P = 0.003). Additionally, there was no significant difference in outcomes of treatment success in patients receiving probiotics (89.4% vs 91.8%; P = 1.00), H2 receptor antagonists (88.9% vs 91.5%; P = 1.00), and proton pump inhibitors (90% vs 91.4%; P = 1.00).


Conclusions: 
We did not identify a significant impact on treatment success between groups that had antibiotics de-escalated or discontinued and those who did not. Though, patients who had antibiotics discontinued or de-escalated had a significantly shorter hospital length of stay compared to the patients who received CAs. A larger sample size will be needed to identify the true impact of this incidental finding.
 
 

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.


BoldItalicUnderlineMore TextAlign LeftAlign CenterOrdered ListInsert LinkInsert ImageInsert Horizontal LineStrikethroughSubscriptSuperscriptFont Family

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: Optimizing Metronidazole Administration: A Comparative Analysis of Every Twelve Hours Versus Every Eight Hours Dosing for Anaerobic Infections 


Authors: Taylor J. Merritt, Kat Petersen, Benjamin Albrecht, Sujit Suchindran, Sarah B. Green 
Emory University Hospital- Atlanta, GA   


Background: Metronidazole has historically been the drug of choice for anaerobic infections, conventionally dosed every eight hours. Its hydroxy metabolite can exhibit 30-65% activity of the parent drug and has a half-life extending up to 11.65 hours. Serum levels of metronidazole exceed the minimum inhibitory concentration at twelve hours for most anaerobes. Thus, an argument that can be made for dosing every twelve hours for most anaerobic infections. The objective of this study is to determine the probability that patients receiving oral or intravenous metronidazole at a dosing frequency of every twelve hours would have a more or equivalent desirable outcome, measured by desirability of outcome ranking (DOOR), than patients receiving a traditional, every eight hours frequency for the treatment of confirmed anaerobic infections.   


Methods: This was a retrospective, quasi-experimental, multi-center analysis which reviewed adult patients who received metronidazole for the treatment of confirmed anaerobic infections. Included patients received 500 mg doses of intravenous or oral metronidazole at a dosing frequency of eight or twelve hours, for at least 72 hours in duration. Patients were excluded if the indication for metronidazole was hepatic encephalopathy, surgical prophylaxis, or treatment of Clostridioides difficile, central nervous system, parasitic, sexually transmitted, or Helicobacter pylori infections. Those who received metronidazole every eight hours for ≥ 72 hours before transition to every twelve hours, received concomitant antibiotics with anaerobic coverage for ≥ 72 hours, or had an organism with documented resistance to metronidazole were also excluded. The primary outcome was the probability that a patient receiving metronidazole every twelve hours would have a more or equivalent desirable outcome than a patient receiving every eight-hour dosing. Secondary outcomes included an assessment of outcomes specific to the subgroup of immunocompromised patients in the study. 


Results: Baseline demographics were similar between the two groups. The majority of included patients were male (55%), Black (62%), and had an average age of 61 years. The average length of stay was 22 days overall, which was also comparable amongst groups. The overall DOOR distribution between groups was similar and there was no significant difference in the probability of a more desirable outcome for patients who received metronidazole every twelve hours compared to traditional every eight-hour dosing (51.3% [95% CI: 43.5%, 59.0%]; p-value= 0.7417). Of the individual DOOR components, there was a statistically significant difference in treatment failure with a higher probability of desired result (i.e. treatment success) in the every twelve-hour dosing group (p-value= 0.021). Analysis of the immunocompromised subgroup also found no difference in probability of desirable outcomes (45.9% [95% CI: 30.1%, 62.6%]; p-value= 0.6388). 


Conclusion: We found no significant differences in desirable outcomes between the dosing groups for total study patients and the immunocompromised subgroup. The results discussed above included criteria for the DOOR analysis such as treatment failure, unsuccessful discharge, adverse effects, and transition to hospice or death. This provides evidence to support that every twelve hours dosing of metronidazole could be considered over every eight hours for most anaerobic infections, due to the similar DOOR ranking in addition to the time saving component, increased convenience for nursing staff, and expected reduction in cost in contrast to dosing every eight hours. 

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: Clinical and Microbiologic Characteristics of Candida auris Isolates at Grady Health System   
 
Authors: Saira Mirza, PharmD; Joseph Corbino, PharmD, MSc; Shreena Advani, PharmD; Joseph Torrisi, PharmD; Sheetal Kandiah, MD, MPH; Susan M. Ray, MD 
 
Objective: The objective of this study was to identify risk factors associated with increased mortality among admitted individuals with pathogenic cultures for Candida auris and assess sensitivities to currently recommended antifungal agents. 
 
Self-Assessment Question: What was a significant risk factor contributing to mortality in this study? 
 
Background: First isolated in 2009 from the ear canal of Japanese individuals, Candida auris has quickly emerged as an important pathogen of worldwide concern. C. auris, similar to other 

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