2025 Southeastern Residency Conference

Title: Evaluation of Enoxaparin Dosing for Venous Thromboembolism Prophylaxis in Low Body Weight Non-Critically Ill Patients


Authors: Andrew Stewart, Alisha B. Terry, Eric Shaw


Background: Enoxaparin is an anticoagulant used for venous thromboembolism (VTE) prophylaxis and treatment. Standard dosing for VTE prophylaxis in adult medical patients is 40 mg daily. There is currently guidance for the dosing of enoxaparin for obese patients with a BMI ≥40 kg/m² but there is minimal guidance for patients with low body weight who are not in the intensive care unit. This study aims to assess the safety and efficacy of reduced dosing strategies for low body weight patients under 50 kg. A retrospective study by Yam et al. found that enoxaparin 30 mg daily achieved target anti-Xa levels in about 74% of low-weight patients without significantly increasing bleeding risk. Other studies, including those by Nemeth et al., Barba et al., and Dybdahl et al., reported no significant difference in bleeding risk between standard and reduced dosing. However, Buckheit et al. and Cappetto et al. found reduced doses were associated with fewer bleeding events. This study compared dosing strategies, evaluated anti-Xa levels, and assessed bleeding and thrombotic events to determine the optimal approach for low body weight, non-critically ill patients.


Methods: This was a retrospective cohort study that was conducted from January 1, 2020, to August 30, 2024, at a 711-bed hospital. It included adult patients, weighing ≤50 kg, who received enoxaparin for VTE prophylaxis for at least 3 days, and had anti-Xa levels measured 3-5 hours after at least the third consecutive dose. Exclusion criteria included patients presenting with a bleed or thrombi, those on anticoagulation on admission, creatinine clearance <30 mL/min, admitted to the ICU, on an orthopedic or trauma service, received an alternative dose of enoxaparin for ≥2 days unless indicated by anti-Xa, did not receive VTE prophylaxis for 48 hours after admission, and pregnant or incarcerated patients. The study compared enoxaparin 20 mg daily vs. 30 mg daily for VTE prophylaxis. The primary outcome was the percentage of patients achieving target anti-Xa levels (0.2-0.4 IU/mL). Secondary outcomes included bleeding (gastrointestinal, genitourinary, hemoptysis, epistaxis, and surgical sites bleeds) and thrombotic events (VTE, pulmonary embolism). 


Results: Of the 1368 patients that were screened, 54 patients were included in the final analysis. Forty-four patients received enoxaparin 30 mg daily and 10 patients received enoxaparin 20 mg daily for VTE prophylaxis. For the primary outcome, the mean anti-Xa level was 0.30 (±0.13) for the 30 mg group and 0.17 (±0.09) for the 20 mg group. The number of patients whose anti-Xa level was in goal for the 30 mg group was 33 (75%) and the number for the 20 mg group was 3 (30%). For the secondary outcomes neither group had a clotting event but the 30 mg group had 2 bleeding events.


Conclusion: This study found that 20 mg of enoxaparin daily for VTE prophylaxis does not on average provide therapeutic anti-Xa levels for non-critically ill adult patients that weigh less than 50 kg. Enoxaparin 30 mg daily for VTE prophylaxis does on average provide therapeutic anti-Xa levels for the specified patient population. Enoxaparin 30 mg daily had more bleeding events compared to 20 mg daily. Therefore, based on this study, non-critically ill adult patients that weigh less than 50 kg should be started on enoxaparin 30 mg daily for VTE prophylaxis because this will result in more therapeutic anti-Xa levels.

Author names: Emily Brackett, Emily Rudisell, Carrie Ellison, DeVon Suber, Ismaeel Yunusa 
 
Background: Pain-related hospital admissions are prevalent in the United States, and in 2016, the CDC released guidelines to assist clinicians with opioid prescribing at discharge. Patients aged ≥ 65 years are particularly vulnerable to inadequate pain control and adverse effects, including dizziness, drowsiness, and constipation. The presence of non-opioid alternatives on the BEERs list further complicates pain management. The CDC recommends the lowest effective opioid dose, with reassessment for doses >50 morphine milliequivalents per day. Prisma Health lacks a discharge opioid protocol, prompting this study to evaluate prescribing patterns in opioid-naïve geriatric patients. 
 
Methods: This retrospective cohort study included patients aged ≥65 years admitted to Prisma Health Richland between January 1, 2024, and August 1, 2024. Eligibility required inpatient admission and an inpatient order for at least 1 opioid for ≥24 hours. The primary objective was to quantify morphine milliequivalents (MMEs) prescribed at discharge. Secondary objectives included comparing inpatient opioid use with discharge regimens, identifying overdose risk factors based on high-risk medications and conditions, evaluating prescribing patterns by provider group, assessing length of therapy, 30-day readmission for opioid adverse reactions, as well as the impact of discharge disposition on MMEs. Statistical analysis will involve one-sample t-tests, Wilcoxon signed-rank tests, paired t-tests, chi-square, and Fisher’s exact tests. 
 
Results: In progress 
 
Conclusion: In progress  

Evaluate safety of DPP4 inhibitors versus mealtime insulin for glycemic control in non-critically ill-hospitalized patients
Graylon Cross-Penn, Aayush Patel, McKenzie Hodges, Kelly Carter
Piedmont Columbus Regional Midtown – Columbus, GA


Background: The management of hyperglycemia in non-critically ill hospitalized patients with type 2 diabetes is often complex and requires a careful balance between glycemic control and the risk of hypoglycemia. Insulin is a common therapy in the inpatient setting, but it carries a risk of hypoglycemia, particularly in patients with lower baseline insulin requirements. Hypoglycemia leads to adverse clinical outcomes, including cardiovascular events, neurological impairment, and prolonged hospitalizations. These risks highlight the need for alternative approach which maintains glycemic control while minimizing the risk of hypoglycemia. Dipeptidyl peptidase-4 inhibitors (DPP-4i) have emerged as a potential alternative for specific populations due to their favorable safety profile, oral route of administration, and tolerability. However, evidence comparing the safety of DPP-4 inhibitors versus insulin in the inpatient setting is limited. This study aimed to address this gap by evaluating the incidence of hypoglycemia and other glycemic outcomes in non-critically ill hospitalized patients receiving either DPP-4 inhibitors or mealtime insulin. The findings may provide critical insights into optimizing glycemic management strategies for hospitalized patients, improving patient outcomes and resource utilization.
Methods: The study reviewed the medical records of non-critically ill patients admitted to Piedmont Hospitals between January 2023 and December 2023. The primary objective was to compare the incidence of hypoglycemia (defined as blood glucose <70 mg/dL) between patients receiving DPP-4 inhibitors and those treated with insulin. Secondary objectives included evaluating the incidence of severe hypoglycemia (BG <50 mg/dL), mean daily blood glucose levels, incidence of hyperglycemia (BG >180 mg/dL), length of hospital stay, total daily insulin requirements, and the number of injections per day.
Patients were included if they were aged 18 years or older, A1C <8% and on outpatient diabetes regimens involving diet alone, oral antidiabetic agents, or insulin therapy of less than 0.5 units/kg/day. Patients were excluded if they were admitted with diabetic ketoacidosis or hyperosmolar state, history of type 1 diabetes, recent glucocorticoid use, ICU admission, history of gallstones, cholecystitis, gallbladder cancer or pancreatitis, blood sugar greater than 400 or less than 70 on admission, patients that underwent surgery, with triglycerides >150 mg/dL, or if they were unable to take oral medications. Statistical analysis was conducted using independent t-tests for primary and secondary outcomes.


Results: In the insulin-only group, there were 14 recorded hypoglycemic events. In the linagliptin with or without insulin group, there were 13 events.
The statistical analysis yielded a p-value of 0.897, indicating no significant difference between the two groups in terms of hypoglycemia risk. The linagliptin and insulin group was much lower with the average daily insulin requirements at 3.94 vs 8.77. This was the only category of the original study that was statistically significant out of the secondary outcomes. The linagliptin group shows significantly higher drug costs—$142.84 compared to $14.57 in the insulin-only group—primarily driven by the high cost of linagliptin ($21/day). When analyzing the linagliptin group only (a subgroup from the linagliptin and correctional insulin) the linagliptin only group out performed the insulin only group, yielding a p-value of 0.029. When further analyzing the linagliptin only subgroup versus the insulin only, it was also statistically significant when comparing average daily blood glucose, number of injections and average daily insulin requirements.


Conclusion: These findings suggest that, in our study population, the addition of a DPP-4 inhibitor did not significantly impact hypoglycemia incidence compared to insulin alone. The total mean cost per patient is nearly 10 times higher in the linagliptin group, highlighting the importance of weighing clinical benefits against financial impact when considering DPP-4 inhibitors in inpatient settings. Standard deviations reflect variability in hospital length of stay. While this chart review provides valuable insights, there are several limitations to consider. First, the data does not represent the United States. Using only linagliptin can be limiting as different DPP4i may have varying efficacy, safety profiles, and patient responses. Additionally, there is differences in diabetes management, which differs across healthcare providers, hospitals, and standard of care groups. These differences in management strategies can impact the consistency of findings and should be considered when interpreting the results. In our analysis, the use of DPP-4 inhibitors was found to be statistically significant when evaluating daily insulin requirements. This suggests that patients on a DPP-4 inhibitor may have different insulin needs compared to those on insulin alone. However, from a cost-effectiveness standpoint, continuing insulin therapy remains a viable and practical option. While our findings provide insight into the potential impact of DPP-4 inhibitors, larger studies with more robust sample sizes are needed to further evaluate their role in non-critically ill hospitalized patients, especially with the linagliptin only group versus insulin only treatment arms.

Contact: graylon.cross-penn@piedmont.org

Title: Evaluation of Direct Oral Anticoagulant Utilization for Venous Thromboembolism Treatment in Obese Spinal Cord Injury Rehabilitation Patients


Authors: Bryce Lackey, Virginia Montgomery, Dina Nakhleh, Raeda Anderson, Chloe Sellers, Carly B. Warner 


Background: Venous thromboembolism (VTE) is a continuous risk for hospitalized patients. Trauma, hypercoagulability, and sedentary lifestyle can increase risk of VTE due to venostasis and clotting factor proliferation. Each of these factors occurs following a spinal cord injury (SCI). Direct oral anticoagulants (DOAC) represent the mainstay of guideline recommended treatment for VTE.  Literature on DOAC use in obesity is evolving, but guidance is limited for DOAC use in patients with both SCI and obesity. This study aims to evaluate DOAC use for VTE treatment in patients with SCI and obesity.  


Methods: A retrospective, single center, cohort study was performed of obese SCI rehabilitation inpatients treated for VTE with a DOAC between July 1, 2019, and July 31, 2024.  The primary objective evaluated the effectiveness of DOAC therapy at preventing recurrent VTE.  Secondary objectives determined the frequency of anticoagulation interruptions, compared rates of VTE recurrence between American Spinal Injury Association (ASIA) scores (ASIA A, B, C, D, and E), and described bleeding events requiring blood transfusions.  For patients meeting inclusion criteria, data collected included: baseline characteristics, select past medical history, body mass index (BMI), weight, level of SCI, ASIA impairment scale, DOAC regimen, and type of VTE.  Patients were evaluated for whether the initial VTE happened prior to admission or at Shepherd Center, and the subsequent initiation of the DOAC regimen.  Those less than 18 years of age, with an indication for anticoagulation other than VTE, or a history of bariatric surgery were excluded.  Data was analyzed using descriptive statistics. Normally distributed data was analyzed via crosstabulations, chi-squared, and gamma tests.  This study was approved by the Institutional Review Board.


Results: The population included 72 patients with an average weight of 110.5kg and BMI of 34.7kg/m2. Average age was 43 years with 83% male and 60% quadriplegic. Patients were treated with apixaban (n=66, 92%) and rivaroxaban (n=6, 8%). Recurrent VTE occurred in eight patients (11%), including three recurrent VTEs while actively on a DOAC regimen.  A DOAC interruption occurred in 25 patients (35%) including five who experienced a recurrent VTE.  A majority of patients (n=39, 54%) had their initial VTE prior to admission and most (n=27) were admitted on a DOAC.  The remaining 33 patients (46%) had their initial VTE while admitted with ten of those patients started on a DOAC within 24 hours of their VTE.  There was no significant association between ASIA scores and the likelihood of having a recurrent VTE (p = 0.194).  There were six patients who required a blood transfusion, and four of those six patients had an accompanying blood hemoglobin level < 7mg/dL.  


Conclusions: This study explores important efficacy and safety outcomes regarding DOAC utilization in obese spinal cord injury patients. The rates of recurrent VTE, interruptions in DOAC therapy, and major bleeding suggest room for optimization in DOAC utilization.  Further research, including multi-center and randomized controlled trials, is needed to validate the findings of this study.  

Title: Evaluation of Electronic Beta-Lactam Allergy Alert Suppression on Carbapenem Prescribing Practices 


Authors: J. Morgan Knight, PharmD, MHIIM; Brandon Hawkins, PharmD, BCIDP, AAHIVP; Erin Anderson, PharmD, BCPS; Skyler Brown, PharmD, BCPS; Brooke Brown, PharmD, BCPS; John R. Yates, PharmD, BCPS; Jason Tuttle, PharmD Candidate; Samantha Walker, PharmD, BCPS 


Objective: The purpose of this study is to determine if the selective suppression of beta-lactam allergy alerts leads to decreased prescribing of carbapenems.


Self Assessment Question: True/False. Selectively alert suppressing allergies based on R1 side chains significantly impacted the volume of carbapenem prescribing


Background: Beta-lactam antibiotics are commonly prescribed in the United States due to their effectiveness and tolerability. Carbapenems are frequently prescribed in the setting of a penicillin allergy due to the low probability of cross-reactivity. Reducing carbapenem prescribing is essential to decrease resistance rates. Clinical decision support assisted alert suppression of beta-lactams with dissimilar side chains may promote increased prescribing of non-carbapenems. 


Methods: This retrospective quasi-experimental study was approved by the institutional review board at a 710-bed academic medical center.  A total of 819 patients were screened between the months of August 2020-October 2024. Patients were assigned to one of two groups: pre- or post-beta-lactam allergy alert suppression implementation. Group 1 included patients pre-alert suppression from August 1st, 2020, to September 25th, 2022. Group 2 included patients post-alert suppression from September 26th, 2022, to October 1st, 2024. Adult patients with a documented beta-lactam allergy who received at least one dose of an antibiotic were included. Exclusion criteria included allergy alerts that were unable to be suppressed due to Cerner coding limitations (e.g., drug classes listed as “penicillins,” or “cephalosporins”) and patients who only received a one-time dose pre-operatively for surgical prophylaxis. The primary outcome is the percentage of patients prescribed any carbapenem for empiric antimicrobial therapy. Secondary outcomes include percentage of patients empirically prescribed a cephalosporin, fluoroquinolone, and aztreonam, and documentation of a new beta-lactam allergy during current admission. A total of 266 patients were required to detect a 15% difference with a power of 90%.


Results: The percentage of patients prescribed any carbapenem in the pre-alert group and post-alert group were 8.04% and 5.17% (p=0.28), respectively. The percentage of patients empirically prescribed a cephalosporin in the pre-alert group versus the post-alert group was 66.7% and 75.9% (p=0.03), fluoroquinolone 4.60% and 6.32% (p=0.78), and aztreonam 6.90% and 4.02% (p=0.24), respectively. Documentation of a new beta-lactam allergy between pre-and post-groups were 2.30% and 2.87%, respectively.


Conclusion: Allergy alert suppression of beta-lactams did not result in a statistically significant difference in prescribing behavior in our study population, but carbapenem prescribing in the post-suppression cohort was numerically lower. To our knowledge, this is a unique approach to investigating allergy alert suppressions based on side chains alone without consideration of reaction type.

Title: Chronic Opioid Use Post ICU Exposure in Opioid Naive Patients


Authors: Hillary Anne Reeves, PharmD; Caitlin Thomas, PharmD, BCCCP


Objective: To assess the prevalence of opioid prescribing and post-discharge opioid use in opioid-naive ICU patients who received scheduled opioids during invasive mechanical ventilation (IMV) weaning. This study aims to identify risk factors for prolonged opioid use and guide opioid stewardship interventions.


Self-Assessment Question: Which of the following best describes a concern associated with the use of opioids for weaning patients from IMV?


1. Opioids used during weaning are often underdosed, leading to withdrawal symptoms.

2. Opioid use during weaning may predispose previously opioid-naïve patients to new prescriptions at discharge and long-term use.

3. Use of opioids during IMV can lead to inadequate sedation and poor weaning outcomes.

4. Opioids are no longer recommended for use in ICU settings due to high misuse rates.

Background: Opioid prescribing in hospitalized patients, particularly those in intensive care units (ICUs), is an area of growing concern due to its potential impact on long-term opioid use. While opioids are commonly used to facilitate weaning from IMV by providing sedation and analgesia, there is limited understanding of their role in continued opioid use after discharge, especially in opioid-naive patients. This study aims to evaluate the practice patterns of opioid prescribing and post-discharge opioid use during IMV weaning. The findings from this study may help guide opioid stewardship efforts and inform strategies for optimizing pain management while minimizing opioid exposure in critically ill patients.


Methods: This is a single-center, retrospective cohort study that has been deemed a quality improvement project and exempt from IRB approval. The study evaluated opioid prescribing patterns in opioid-naive ICU patients who received scheduled opioids during IMV weaning at a large, tertiary level, community teaching hospital. The electronic medical record (EMR) and Prescription Drug Monitoring Program (PDMP) will be used to evaluate opioid prescribing patterns at discharge and outpatient use. Patients > 18 years old admitted to the ICU, mechanically ventilated for > 3 days, and receiving scheduled opioids during IMV weaning will be included. Patients are excluded if they have a documented history of chronic opioid use or opioid use disorder prior to ICU admission, patients discharged to hospice or palliative care, major surgery at any point during admission, or incomplete medical records that do not provide sufficient data for analysis. EMR data from January 2023 -December 2023 will assess opioid initiation in the ICU, with PDMP review for up to 1-year post-discharge to evaluate outpatient opioid use. This study will compare patients who received scheduled opioids during IMV weaning to those who did not, identifying factors associated with outpatient prescribing and long-term opioid use. 


Results: A total of 531 patients were screened, resulting in 58 patients who met inclusion criteria. Of these, 47 patients comprised the comparator group (no scheduled opioids during weaning), while 11 patients made up the study group (received scheduled opioids during weaning). The primary outcome showed no statistically significant difference (p=1.00) in the number of patients discharged with an opioid prescription between the two groups. Six patients in the comparator group were discharged with an opioid prescription, compared to one patient in the study group.


Conclusions: This study explored the relationship between scheduled opioid administration during invasive mechanical ventilation (IMV) weaning and subsequent outpatient opioid prescribing in opioid-naïve ICU patients. Although the study was underpowered, the results did not show a significant increase in discharge opioid prescribing among patients who received scheduled opioids during IMV weaning compared to those who did not. These findings suggest that current prescribing practices at our institution may reflect appropriate tapering or discontinuation of opioids prior to discharge, even among patients exposed to scheduled opioids during their ICU stay.

Title: Real world analysis of safety and efficacy outcomes in lymphoma patients receiving CAR T-cell therapy with prophylactic dexamethasone

Authors: Alleah Al-Amery, Karin Abernathy, Darby Siler, Laura Beth Parsons, and Chelsea Mitchell

Background: Axicabtagene ciloleucel (axi-cel) and brexucabtagene autoleucel (brexu-cel) are CD19-directed chimeric antigen receptor T-cell (CAR-T) therapies used to treat certain B-cell malignancies. Administration of CAR-T requires monitoring and management of potential adverse events, including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Prior studies have demonstrated a reduced incidence of CRS and ICANS with prophylactic dexamethasone in axi-cel recipients without compromising efficacy. Though brexu-cel shares a similar structure to axi-cel, there are no studies assessing effect of corticosteroid prophylaxis in this population. This study seeks to bridge the gap in the literature and assess institutional practice regarding prophylactic dexamethasone in both axi-cel and brexu-cel recipients.

Methods: This was a retrospective study at a tertiary medical center, including patients who received axi-cel or brexu-cel for a lymphoma diagnosis between June 1, 2020 and July 31, 2024. Patients were excluded if they did not receive prophylactic dexamethasone on days 0, +1, and +2, were enrolled in a clinical trial, received CAR-T as an inpatient, were under 18 years old, or were treated on the pediatric oncology service. The primary endpoint was incidence of all-grade CRS and ICANS, compared to a historical control. Secondary endpoints included time to onset, severity, duration, and resolution of CRS and ICANS, as well as hospitalization rates, disease response at Day 30, and survival at Day 30.
 
Results: Of the 32 patients screened, 27 (axi-cel: N=17 ; brexu-cel: N=10) were included. Baseline demographics were similar between both axi-cel and brexu-cel groups and the respective historical controls. The axi-cel group had similar rates of CRS compared with historical controls that also received prophylactic dexamethasone (88% vs. 80%; p=0.70). Overall incidence of ICANS was lower (35% vs 53%, p=0.16) than historical comparator. Similarly, Grade 3+ ICANS was lower than comparator group (5.8% vs. 12.5%, p=1.00). The brexu-cel group had a lower rate of CRS compared with historical controls that did not receive prophylactic dexamethasone (80% vs. 91%, p=0.27). Though not statistically significant, the brexu-cel group had lower incidence of Grade 3+ CRS compared with historical controls (0% vs. 15% p = 0.60). Incidence of ICANS was similar across brexu-cel groups (60% vs. 63%, p=1.00). However, Grade 3+ ICANS was lower in the brexu-cel group compared with historical controls (10% vs. 31%, p=0.66). Median days to onset of CRS and ICANS were delayed with the addition of prophylactic dexamethasone prior to brexu-cel (CRS: 7 vs. 2, p =0.06; ICANS: 10 vs. 7, p=0.70).
 
Conclusion: This real-world assessment of prophylactic dexamethasone with axi-cel showed comparable results to the historical studies. Prophylactic corticosteroids with brexu-cel appears to decrease severity of both CRS and ICANS while also delaying onset. These results could increase feasibility of outpatient administration of brexu-cel. These results also mirror outcomes with dexamethasone prophylaxis with axi-cel.

Disclosure: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities. 

Title: Determining the Therapeutic Dosage of Enoxaparin Anticoagulation Among Morbidly Obese Patients After the Implementation of an Automatic Clinical Pharmacy Anti-Xa Monitoring Service Using Enoxaparin Dosing Protocol
Authors: Kelsey Green, Michael Ezebuenyi, Jennifer Jones, Danielle Ricks, and Gregg Davis
Objective: The purpose of this study is to determine the required dose of enoxaparin in mg/kg to attain therapeutic anti-Xa levels in morbidly obese patients. 
Background: Enoxaparin is a low-molecular weight heparin (LMWH) used for prophylaxis and treatment of venous thromboembolism (VTE), acute coronary syndromes (ACS) and stroke prevention in atrial fibrillation. Most patients receiving LMWH do not need laboratory monitoring. However, monitoring anti-Xa levels in patients with morbid obesity is recommended due to variations in pharmacokinetic parameters which affect drug concentrations. Currently, there is no standardized dosing regimen for the morbidly obese patient population. 
Methods: This study is a single-center retrospective electronic chart review conducted from August 2021 to August 2024. This study has been approved by the Institutional Review Board at Our Lady of the Lake Regional Medical Center (OLORMC). The electronic medical record was used to identify eligible patients, which include adults with a BMI greater than or equal to 35 kilograms per square meter or total body weight greater than or equal to 150 kilograms who are initiated on treatment dosing of enoxaparin. OLOLRMC employs an automatic consult for a clinical pharmacist-driven anti-Xa protocol, which was implemented in 2019, for monitoring and adjusting enoxaparin doses for morbidly obese patients. Data was collected on the initial enoxaparin dose, initial anti-Xa levels, enoxaparin dose at goal anti-Xa level, the time (in days) to reach therapeutic anti-Xa level, length of hospitalization and the occurrence of adverse bleeding events. Descriptive statistics along with other relevant statistical tests, such as regression and correlation, will be utilized in the analysis of collected data. The primary outcome of the study is the required enoxaparin dose in mg/kg to attain two therapeutic anti-Xa levels. Subgroup analyses are planned to compare the doses of enoxaparin across BMI ranges, renal function, and different indications. 
Results: Overall, the enoxaparin dose at time of second consecutive therapeutic anti-Xa level was found to be 0.77 mg/kg (IQR 0.60, 0.84). The median time to attain two consecutive therapeutic anti-Xa levels was 154 hours (IQR 76, 221). Out of the patients weighing greater than or equal to 155 kg who had initial doses capped at 150 mg, had lower rates of supratherapeutic levels and improved time to two consecutive anti-Xa levels. In addition, one limitation of our study was 20% of anti-Xa levels were unable to be assessed due to being drawn outside of the peak window. 
Conclusion: In conclusion, lower initial enoxaparin doses of ~0.75 mg/kg and appropriate drawing times of anti-Xa levels would improve the ability and time to reach therapeutic anti-Xa levels in morbidly obese patients. 

Title: Pharmacist Driven Penicillin Allergy De-escalation using the PEN-FAST Allergy Decision Rule
Authors: Ny'Asia Cleckley, Molly Thompson, Jessica Sutton
Background: 
β-lactam allergies, specifically allergies to penicillin, are the most commonly reported antibiotic medication allergies in the hospital setting. However, according to the American Academy of Asthma, Allergy, and Immunology (AAAAI) Joint Task Force, 90% of patients with a reported penicillin allergy are able to tolerate the penicillin drug class.
The PEN-FAST penicillin allergy assessment is a clinical decision-making tool designed to be a quick and low burden method to identify patients with low-risk penicillin allergies who would likely have a negative result if formal penicillin allergy testing was conducted. The mnemonic PEN-FAST describes the risk score of true penicillin allergy based on the following queries: five years or fewer since the reaction (2 points), anaphylaxis/angioedema or severe cutaneous adverse reaction (SCAR) (2 points), and treatment required for the reaction (1 point).  Trubiano et al (2020) validated the PEN-FAST assessment with results showing it to have a high negative predictive value of 96.3% in scores less than 3 points, coinciding with the cutoff for low risk penicillin allergies.  
Methods: A single-center, retrospective, cohort analysis conducted on adult (>18 years old) patients with a documented penicillin allergy admitted to Trident Medical Center from February 2025 to April 2025. The study is pending exempt review by the health system’s Institutional Review Board. Eligible patients included non-pregnant adults with a penicillin allergy documented in electronic medical record (EMR) who were screened during an admission within the defined timeframe using the PEN-FAST assessment. Patients were excluded from the study if there was a documented allergic reaction of anaphylaxis (throat/mouth swelling, trouble breathing) or SCAR to penicillin in the EMR or were unable/unwilling to participate in the interview. The primary outcome of this study is the incidence of patients with a PEN-FAST score less than 3 points correlating with low risk of true penicillin allergy. Secondary outcomes include penicillin allergy de-labeling, post-screening oral amoxicillin challenge, antibiotic selection, antibiotic-associated adverse events and the time required for patient interview. The patients’ electronic medical record will be used to collect data on patient demographics, PEN-FAST screening result, antibiotic selection, antibiotic-associated adverse events and use of a post-documentation amoxicillin oral challenge.
Results: In progress
Conclusion: In progress

Cefazolin Plus Metronidazole Compared to Cefoxitin Alone for Surgical Prophylaxis in Hysterectomies
Tristan Jernigan, Austin Roberts, Kendra Spilkin, Benjamin Casey
Background: Antibiotic prophylaxis is a critical component of surgical site infection prevention in hysterectomy procedures. The 2013 IDSA guidelines recommend cefazolin, cefoxitin, or ampicillin-sulbactam as first-line agents, administered within one hour prior to surgical incision. When choosing between the guideline recommendations it is important to consider reported efficacy and the logistical implications of different regimens. Cefazolin is redosed every four hour while cefoxitin is redosed every two hours. In a 2017 study by Till and colleagues, cefazolin combined with metronidazole reduced the incidence of post-operative infections compared to cefoxitin alone in hysterectomy patients. Based on these findings, our institution transitioned from cefoxitin to a cefazolin plus metronidazole regimen in May 2022. This study evaluated the impact of this change on compliance with surgical prophylactic antibiotic administration, focusing on whether this transition increased appropriate prophylaxis rates by leveraging cefazolin’s longer dosing interval to reduce the incidence of missed or delayed prophylactic doses.
Methods: This was a single-center, retrospective, pre and post implementation cohort study of adult patients who underwent a hysterectomy between November 15th, 2021 and November 14th, 2022. Patients were identified by a generated list of patients who underwent a hysterectomy during the designated time frame and were randomized. Patients were included if prophylactic antibiotics were administered. Patients were excluded based on extremes of age or if clindamycin and gentamicin were administered for surgical prophylaxis. The primary endpoint was the percentage of patients who received appropriate antimicrobial surgical prophylaxis. Appropriate prophylaxis was defined as preoperative administration within one hour of surgical incision and subsequent redosing within thirty minutes of the recommended frequency. The secondary endpoints included the incidence of post-operative infection, direct drug cost with each regimen, and a subgroup analysis of the primary outcome to evaluate reasons for inappropriate prophylaxis. 
Results: A total of 260 patients were screened, and 226 (n = 140 cefoxitin, n = 86 cefazolin plus metronidazole) met criteria for our study. Patients who received clindamycin plus gentamicin for surgical prophylaxis (n=34) were excluded from the primary and secondary endpoints. Baseline characteristics were similar between the two groups. Cefoxitin was associated with significantly higher appropriate prophylaxis rates when compared to cefazolin plus metronidazole (88.6% vs. 76.8%, p=0.009). There was no significant difference in post-operative infections between the two groups (0.4% vs. 0%, p=0.32). Subgroup analysis of the primary outcome found significantly more cases of inappropriate dosing in the cefazolin plus metronidazole group (4.7% vs 0%, p=0.02) and significantly more cases of redosing errors with cefoxitin (2.9% vs. 0%, p=0.04).
Conclusion: While cefoxitin was associated with higher rates of appropriate prophylaxis, the primary reason for inappropriate prophylaxis in the cefazolin plus metronidazole group was the use of cefazolin alone for prophylaxis, which is an appropriate, guideline-recommended prophylaxis regimen. Cefoxitin was associated with a higher rate of redosing errors when compared to cefazolin plus metronidazole. Overall rates of post-operative infection were low, with no significant difference being observed between the two groups. 
Disclaimer: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

TITLE: Comparison of Analgesia Following Coronary Artery Bypass Grafting with the Use of Scheduled Acetaminophen
 
AUTHORS: Morgan Carhart, Brock Dorsett, Emily Johnson, Kayla Pangburn
BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols are comprehensive, patient-centered, and evidence-based protocols that improve post-operative patient outcomes. Pain management is a major focus of ERAS protocols, which advocate for a multimodal, opioid-sparing approach to reduce hospital length of stay (LOS), complications, and opioid use following surgery. Intravenous (IV) acetaminophen (Ofirmev) is often used as a part of ERAS protocols and its use in the post-operative setting has been established for many different procedures. However, there are relatively few studies examining its use post-cardiac surgery and its benefits in terms of reducing post-operative opioid consumption are unclear. In January 2024, Cape Fear Valley Medical Center implemented an ERAS protocol for patients undergoing coronary artery bypass grafting (CABG) that includes one dose of IV acetaminophen followed by scheduled oral acetaminophen and as-needed hydromorphone via patient-controlled analgesia (PCA) pump. The purpose of this study was to evaluate the effects of initiating scheduled acetaminophen following CABG on the utilization of opioids during the first 48-hour post-operative period.
METHODS: This was a retrospective, single-center cohort study that included patients receiving CABG at Cape Fear Valley Medical Center from January 2023 to December 2024. The pre-ERAS group included patients receiving CABG from January to December 2023, and the post-ERAS group included patients receiving CABG from January to December 2024 that received the scheduled acetaminophen protocol. The primary endpoint was the difference in mean oral morphine milligram equivalents (oMMEs) used by patients receiving CABG before and after the implementation of the ERAS protocol at Cape Fear Valley Medical Center.
RESULTS: 301 patients met inclusion criteria with 143 in the pre-ERAS group and 157 in the post-ERAS group. Patients in the pre-ERAS group used a mean of 179.25 oMMEs compared to 193 oMMEs in the post-ERAS group (difference 13.75, 95% CI -42.22 to 14.72, p=0.34). There were no significant differences in secondary endpoints including as-needed opioid use, length of stay, or naloxone use between groups, but patients in the pre-ERAS group used more non-opioid pain medications than patients in the post-ERAS group (40 vs. 26, p=0.017).
CONCLUSION: The use of scheduled acetaminophen post-CABG did not significantly reduce the amount of total oMMEs for patients undergoing CABG within the 48-hour post-operative period. Limitations to the study that should be considered include the retrospective nature of this study, utilization of acetaminophen post-CABG in the pre-ERAS group, and a higher number of opioid-tolerant patients on admission in the post-ERAS group.

Title: COMPARISON OF HIGH-DOSE VERSUS LOW-DOSE SYSTEMIC CORTICOSTEROIDS FOR ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN  NON-CRITICALLY ILL PATIENTS
Authors: Hanna Condrey, Alexis Chlada, Sharon Jordan
Practice Site: Grand Strand Medical Center – Myrtle Beach, SC
Background/Purpose: This study aims to compare the outcomes of non-critically ill patients receiving high-dose versus low-dose systemic steroids for acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD).
Methodology: This retrospective cohort study included 2,277 patients aged ≥ 18 years, who were admitted for acute COPD exacerbation and received at least 2 days of any dose of glucocorticoids. Patients were categorized into two groups based on their daily steroid dose: high-dose (> 40 mg prednisone equivalents per day) or low-dose (≤ 40 mg prednisone equivalents per day). The primary outcome was length of stay (LOS). Secondary outcomes included 30-day and 90-day readmission rates, as well as the incidence of hyperglycemia and hypertension during hospitalization.
Results: In-Progress
Conclusions: In-Progress
Disclaimers: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Title: Effect of Bupivacaine Liposome Injectable Suspension Administration in Abdominal Surgery


Authors: Allison Daneault, John Shadowen, Will Johnson, Elizabeth Oglesby


Objective: Define the efficacy outcomes used for bupivacaine liposome injectable suspension in the studied abdominal surgical population.


Self Assessment Question: Based on the findings of this study, which outcome was reduced in the bupivacaine liposome injectable suspension treatment group?
A. Patient reported pain scores
B. Hospital length of stay
C. Opioid usage


Background: Uncontrolled post-operative pain can lead to an increased need for analgesics and contribute to increased length of hospital stay. Bupivacaine liposome injectable suspension is an extended-release local anesthetic approved to reduce post-surgical pain for up to 72 hours. This study compared outcomes in patients that received bupivacaine liposome injectable suspension versus patients that received another local anesthetic prior to an abdominal procedure. The goal of this study was to determine if there is additional benefit associated with injectable bupivacaine liposome in decreasing opioid use as compared to other local anesthetics. 


Methods: A retrospective chart review was conducted comparing surgical patients who received bupivacaine liposome injectable suspension compared to those receiving an alternative local anesthetic. Abdominal surgical patients from April to October 2023 that received injectable bupivacaine liposome prior to the procedure were analyzed to be included in the study. Data from the comparator group were collected from April to August 2016 prior to the utilization of injectable bupivacaine liposome at Mobile Infirmary Medical Center. The primary outcome of this study was to compare the difference in mean morphine milligram equivalents (MME) administered within the first 72 hours after surgery between the two treatment groups. Secondary outcomes included length of hospital stay (LOS), pain scores (12, 24, 48, and 72 hours post-operation) on a numeric 0-10 scale, time to first post-operation bowel movement, discharge opioid prescriptions, and all cause 30-day readmission. Exclusion criteria included non-abdominal procedures, patients with less than a 24-hour hospital stay, outpatient surgeries, and patients that remained intubated for the first 72 hours post-operation.


Results: Each group contained 75 patients amounting to a total of 150 patients in the study sample.  65% of the abdominal surgeries in the injectable bupivacaine liposome group were colectomies compared to 77% of procedures using an alternative anesthetic. 93% of the injectable bupivacaine liposome group underwent robotic surgeries versus 58% of the control group. There was no significant difference in the primary outcome of mean number of MME between the two groups (injectable bupivacaine liposome 69.91 ± 55.26 vs control 74.47 ± 59.01, p = 0.618). There was, however, a significant difference found between the average LOS in the injectable bupivacaine liposome group compared to control (111.23 hours ± 67.01 versus 212.52 hours ± 171.21, p < 0.0001), which equates to approximately double the LOS for the patients prior to injectable bupivacaine liposome use at Mobile Infirmary. Subgroup analysis of LOS of robotic and laparoscopic procedures also showed a significantly shorter LOS for patients receiving injectable bupivacaine liposome (105.76 hours ± 57 (n = 70) versus 180.77 hours ± 164.44 (n = 42), p = 0.0007).    


Conclusion: Bupivacaine liposome injectable suspension did not exhibit a significant difference in MME utilization in the patients reviewed in this study. However, there was a statistically significant shorter length of hospital stay. A limitation of this study was that the comparator sample was from before injectable bupivacaine liposome was used at Mobile Infirmary, leading to an 8-year gap between the patient groups. In this timeframe, surgical techniques have advanced, and the hospital has instituted enhanced recovery protocols that this study was not able to account for. Further research is needed to account for these variables.

Authors: Akua Kuffour, Brianna Qualls, Christine Wong, Devon Tousignant 
Purpose: Erythropoiesis-stimulating agents (ESAs) are commonly utilized in the management of anemia associated with chronic kidney disease (CKD). Despite the established efficacy of these agents, the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Anemia in CKD recommends that the potential benefits of ESAs should be balanced against the potential risks of ESAs, which include hypertension and thromboembolism. Pharmacists can significantly contribute to the safe and effective use of ESAs through dose adjustments, order modifications, and continuous monitoring. This study aimed to assess the impact of a pharmacist-led ESA management protocol of hospitalized patients with CKD-related anemia. 
Methods: This study received an exemption from the Institutional Review Board. Using a quasi-experimental, retrospective comparative design, it assessed utilization of ESAs for anemia in CKD before and after the implementation of a pharmacist-driven management protocol. The pre-intervention group reflected nephrology-driven ESA management of anemia in CKD with data collected from November 01, 2023 to March 30, 2024. A locally approved protocol to provide guidance on pharmacy-led optimal initial ESA dosing, dose adjustments, monitoring parameters, and iron repletion was created with approval by nephrologists and the Pharmacy and Therapeutics Committee. All pharmacists and dialysis nurses were educated regarding the new process and protocol. The post-intervention period reflected pharmacy-driven ESA management of anemia in CKD from December 24, 2024 to February 28, 2025. Data was collected through retrospective chart review, capturing relevant patient information including ESA doses administered, transferrin saturation, ferritin levels, hemoglobin concentrations, hemodialysis status, adverse events, and pharmacist interventions. The primary outcome assessed the incidence of hemoglobin values within target range (10 g/dL – ≤ 11.5 g/dL). Secondary outcomes included the incidence of appropriate iron repletion when indicated, incidence of blood transfusion after ESA initiation and incidence of hemoglobin level > 11.5 g/dL.  
 Results: A total of 160 patients were included, 83 in the pre-intervention group and 77 in the post-intervention group. For the primary outcome, the incidence of hemoglobin values within the target range (10 g/dL – ≤ 11.5 g/dL) was 14.82% in the pre-intervention group and 21.45% in the post-intervention group (p < 0.001).  Compared with the pre-intervention group, the incidence of appropriate iron repletion when indicated was higher in the post-intervention group (17% vs. 57%; p= 0.003). The incidence of hemoglobin > 11.5 g/dL occurred in 5.51% in the pre-intervention group and 2.55% in the post intervention group (p= <0.001). Blood transfusion after ESA initiation occurred in 1.2% in the pre-intervention group and 3.9% in the post-intervention group (p= 0.276).  
Conclusion: The pharmacist-driven ESA management protocol for anemia in chronic kidney disease significantly improved the attainment of target hemoglobin levels and appropriate iron repletion. The protocol effectively prevented overcorrection of hemoglobin levels, reducing the risk of adverse cardiovascular events.  

Tittle: Description of a 24-hour Therapeutic Target in Hospitalized Patients with Acute Coronary Syndrome or Atrial Fibrillation Before and After Implementation of a Maximum Initial Weight-Based Unfractionated Heparin Dosing Limit
 
Authors: Ivonne Marie Santiago Lopez, Kristen Keen, Justin Hodges, Ruthanne Baird, Catherine L. Wente, Dustin Wilson & Richard Drew
Cape Fear Valley Betsy Johnson Hospital – Dunn, NC
 
Objective: To describe the rate of 24-hour therapeutic target attainment in hospitalized adult patients ³ 85 kg with ACS or AF receiving UFH before and after implementation of a maximum initial dose protocol.


Self-Assessment Question: What is one reason that dose capping was implemented in this study?

Background: Unfractionated heparin (UFH) is commonly used for anticoagulation in critically ill patients but presents challenges in dosing for those weighing over 100 kg due to altered pharmacokinetics. Conservative dosing practices, such as capping doses, can delay therapeutic target attainment, potentially increasing the risk of adverse outcomes like venous thromboembolism (VTE) and coronary events. This study evaluates the impact of a weight-based, capped UFH dosing protocol on 24-hour therapeutic target attainment and bleeding complications in patients with acute coronary syndrome (ACS) and/or atrial fibrillation (AF)
Methods: This retrospective cohort study reviews medical records from patients admitted to Cape Fear Valley Betsy Johnson and Central Harnett Hospitals between September 2023 and December 2024. Eligible patients (≥ 85 kg with ACS/AF as dose cap begins at this weight) who received UFH were analyzed for the rate of achieving therapeutic levels within 24 hours before and after the implementation of a weight-based capped dosing protocol in May 2024. Secondary outcomes include the incidence of bleeding complications, number of coagulation tests required to achieve therapeutic targets (anti-Xa 0.3 – 0.7 units/mL or aPTT 53 – 73 seconds, and the use of heparin reversal agents. Data were collected via electronic health records (EHR) and analyzed using an intention-to-treat approach with JMP version 17.


Results: The primary outcome of achieving therapeutic anticoagulation at 24 hours was observed in 78% of patients in the control group, compared to 64% in the intervention group (OR 1.09; 95% CI 0.4,2.96). Regarding secondary outcomes, bleeding complications were reported in 7% of the first group and 12% in the second group, with all cases being minor. Protamine was not administered in any of the patients during their hospital stay. The number of coagulation laboratory draws required to achieve therapeutic targets was lower in the control group, with 60% patients needing only one draw compared to 46% in the intervention group.

Conclusions: There was no statistically significant difference between the groups in achieving therapeutic targets at 24 hours. While no major bleeding events occurred in either group, the intervention group had a higher incidence of minor bleeding. Additionally, neither group required protamine for reversal. These findings suggest that, overall, both treatments were safe, but further research with a larger sample size is needed to better understand the true impact of the intervention.

Background/Purpose:  

Venous Thromboembolism (VTE) is a major public health issue, affecting about 900,000 people annually in the United States, and is the leading preventable cause of in-hospital mortality. Current guidelines recommend direct oral anticoagulants (DOACs) over vitamin K antagonists, like warfarin, for VTE due to their favorable pharmacokinetic profile, fewer interactions, and lack of routine monitoring. However, the safety and efficacy of DOACs in patients with extreme body weight remain uncertain. Obesity, defined as body mass index (BMI) ≥ 30 kg/m2, is a known risk factor for VTE, with mechanistic links to venous stasis, endothelial dysfunction and hypercoagulability. Despite this, obese individuals have been underrepresented in major randomized controlled trials that assess the efficacy of DOACs in treating VTE, leading to uncertainties regarding optimal anticoagulation.  

 In 2016, the International Society of Thrombosis and Haemostasias (ISTH) recommended warfarin over DOACs for patients with a BMI ≥ 40 kg/m2 or weight ≥ 120 kg due to concerns of reduced drug exposure with fixed dose DOACs. Though pharmacokinetic data suggest that obese patients may achieve therapeutic levels with DOACs, more clinical evidence is needed for definitive recommendations in this patient population. In 2021, ISTH updated their stance to recommend DOACs in all patients regardless of BMI, however clinical evidence in severely obese populations remains limited. This study aimed to evaluate the safety and efficacy of DOACs in obese patients compared to non-obese patients being treated for VTE at Emory Decatur Hospital.   


Methods:  

This was a single-center, IRB-approved, retrospective study conducted from October 2022 through November 2024. Patients were included if they were ≥18 years of age, diagnosed with a VTE and treated with a DOAC. Patients were excluded if they were on anticoagulation for any other indication. Patients were stratified into morbidly obese and non-morbidly obese patient groups. Morbid obesity was defined as BMI ≥40 kg/m2 or weight ≥ 120 kg. The primary outcome was the incidence of recurrence of VTE within 12 months. Secondary outcomes included all-cause mortality, VTE-related mortality, and length of stay. Safety outcomes include major bleeding events, clinically relevant non-major bleeding events and adverse drug reactions.  

Results:

The incidence of recurrence of VTE within 12 months occurred in 7.3% of patients in the BMI <40 kg/m2 group (n=4) and 2% of patients in the BMI ≥40 kg/m2 group (n=1) (OR 0.26, 95% CI [0.027-2.46], p-value 0.367). There was one death from all-cause mortality in the BMI ≥40 kg/m2 group and no deaths occurred in the BMI <40 kg/m2 group (p-value 0.47). No VTE related mortality was observed. The median length of stay was 50.5 hours in BMI < 40 and was 51.8 hours in the BMI ≥40 kg/m2 group (p-value 0.44). Major bleeding events occurred in 5% of patients in the BMI <40 kg/m2 group (n=3), while 6% of patients had major bleeding events in the BMI ≥40 kg/m2 group (n=1) (OR 1.13, 95% CI [0.217-5.88], p-value 1). Non-major bleeding events occurred in 12% of patients in the BMI < 40 kg/m2 (n=7) and in 6% of patients in the BMI ≥40 kg/m2 (n=3). 

Conclusion: 

The use of DOACs in patients with morbid obesity may be a safe and effective option for VTE treatment, with no observed increase in recurrent VTE or bleeding events. However, larger randomized controlled trials are needed to fully evaluate their efficacy and safety in this population.

Title: Evaluation of Outpatient Parenteral Antimicrobial Therapy (OPAT) in a Community Healthcare System
 
Authors: Giovanna Brannon, Chris Whitman, Rachel L. Foster, Kelly Huff, Nichole Moore, Charles Hartley
 
Objective: Describe the pharmacist's role in OPAT management, such as review of antimicrobial selection and adverse event monitoring, to optimize patient safety and reduce hospital readmissions
 
Self Assessment Question: What are potential risk factors associated with unplanned healthcare events that pharmacists can identify in patients receiving OPAT?
 
Background: Outpatient parenteral antimicrobial therapy (OPAT) enables patients to complete extended courses of antimicrobial treatment for serious infections at home or in a step-down facility following hospital discharge. OPAT discharges require a multidisciplinary and well-coordinated approach. The Infectious Diseases Society of America OPAT guidelines recommend all patients should have infectious diseases (ID) experts review prior to initiation of OPAT. Prior studies have shown improved patient safety, improved patient outcomes, and reduction in healthcare costs when ID-trained pharmacists are involved. No formal OPAT program exists at this hospital system. The purpose of this study is to evaluate the OPAT prescribing and management practices across the Infirmary Health system (IHS) in order to understand factors associated with hospital readmissions and improve patient safety and efficiency through streamlining and standardizing the OPAT discharge process.

Methods: In this retrospective epidemiological cohort study, data was collected on patients at least 19 years of age who were discharged with orders to receive parenteral antimicrobials between May 1, 2023 and April 30, 2024. Patients meeting any of these three criteria were screened for inclusion: 1) Discharge order for an intravenous antimicrobial, 2) Order for vascular access for intention of OPAT, or 3) Case management order containing specific OPAT orders. Patients were excluded if they completed the entire planned OPAT course prior to hospital discharge. The primary outcome is the rate of unplanned healthcare events within 30 days of completing OPAT therapy. The secondary outcomes include qualitatively describing the OPAT patient population, hospital length of stay, and 30-day mortality. A sub-group analysis was conducted to evaluate risk factors associated with unplanned healthcare events.

Results: There were 1244 patients who received OPAT during the study period; 101 patients were included in the final analysis after randomization. The median age of patients included was approximately 63 years old (IQR 52-73). The most common infectious diagnoses were osteoarticular (30%), skin and skin structure (18%), endovascular (16%), urologic (16%), and complicated intra-abdominal (14%). Ceftriaxone and vancomycin were the most commonly prescribed antimicrobials. Of the 101 patients evaluated, 42 experienced a 30-day unplanned healthcare event. Of these 42 patients, 25 (60%) of the unplanned healthcare events were OPAT or infection related.  

Conclusion: OPAT patients experienced a high rate of 30-day unplanned healthcare events. Opportunities exist within our healthcare system to improve the OPAT workflow and to enhance safety and efficiency. The results of this study demonstrate the opportunity for our healthcare system to implement a formal multidisciplinary OPAT inpatient review program. This would include ID-trained pharmacists who will review OPAT orders and provide treatment recommendations regarding OPAT modality, antimicrobial selection, outpatient safety and efficacy monitoring, and patient counseling.  

Title: Evaluation of Low Molecular Weight Heparin Dosing in Obese and Non-Obese Patients Using Anti-Factor Xa Levels


Authors: Samantha Bailey, Paige Nickelsen, Hana Davis, Laura Beth Parsons


Background: Enoxaparin is a low molecular weight heparin widely used in the inpatient setting for the treatment and prevention of venous thromboembolism (VTE). Hospitalized patients with a BMI ≥ 40 kg/m2 are at an increased risk of developing VTE due to increased abdominal pressure, inactivity, chronic low-grade inflammatory state, and impaired fibrinolysis. However, enoxaparin’s pharmacokinetics in obese patients are unpredictable and may be altered by rate of absorption, volume of distribution, and renal clearance. Due to its variable kinetics, there is no clear consensus on dosing enoxaparin in obese patients. It is necessary to establish more distinct dosing recommendations to ensure that patients are adequately anticoagulated without increasing the risk of adverse events, such as bleeding and thrombosis. In order to further assess adequate anticoagulation with enoxaparin in extremes of weight, investigators of this study aimed to compare peak anti-factor Xa levels and enoxaparin dosing regimens between patients with varying weights.


Methods: This is a retrospective cohort study conducted at a tertiary medical center. Patients were identified via a generated report of low molecular weight heparin anti-factor Xa orders from August 1, 2019 through August 1, 2024. Exclusion criteria consisted of patients with no active order for enoxaparin at time of anti-factor Xa level drawn, anti-factor Xa level not drawn at steady state, less than 18 years of age, pregnant, and incarcerated patients. The primary endpoint was incidence of therapeutic anti-factor Xa levels in patients receiving enoxaparin at prophylactic or treatment doses based on BMI. Secondary endpoints included incidence of therapeutic anti-factor Xa levels in patients receiving enoxaparin at prophylactic or treatment doses based on weight, incidence of thrombotic events, and incidence of bleeding events. Additional secondary endpoints were assessed by a subgroup analysis of patients with only therapeutic anti-factor Xa levels: dose evaluation in mg/kg for VTE prophylaxis or treatment based on BMI group and dose evaluation in mg/kg for VTE prophylaxis or treatment based on weight group.


Results: A total of 64 patients were included in this study: n=14 in the prophylaxis group and n=50 in the treatment group. In the prophylaxis group, the mean weight and BMI were 148.1 (±52.1) kg and 51 (±17) kg/m2, respectively. The mean prophylactic enoxaparin dose was 0.45 (±0.14) mg/kg, with 7 (50%) patients having a therapeutic anti-factor Xa level. In the treatment group, the mean weight and BMI were 113.1 (±37.6) kg and 38 (±13) kg/m2, respectively. The mean treatment enoxaparin dose was 0.95 (±0.11) mg/kg, with 18 (36%) patients having a therapeutic anti-factor Xa level. Among the non-therapeutic levels, the majority were supratherapeutic in both the prophylaxis (36%) and treatment (52%) groups. There were no major differences between anti-factor Xa levels when comparing weight versus BMI. Adverse events only occurred within the treatment group: bleeding in 6 (12%) patients.


Conclusion: Standard enoxaparin dosing may not be appropriate in patients with extremes of weight. While anti-factor Xa levels varied between different weight and BMI groups, our results suggest that we may be overdosing obese patients. Anti-factor Xa levels may be beneficial in guiding enoxaparin dosing in obese patients. 


This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Title: Evaluation of Pharmacist-Initiated Dose Adjustment of Prophylactic Enoxaparin in Low Body Weight Patients 
 
Authors: 

• Cody Seward
• Breanne Wofford
• Kimberly Keller
• Brooke Brown
• Kaylee Behal
• Shaun Rowe
• Sarah Crowell
• Miller Hadley
• Ava Mosadegh

 
Objective: Compare the impact of a Pharmacy & Therapeutics (P&T) committee-approved protocol for pharmacist-driven adjustment of prophylactic enoxaparin dosing among low body weight patients pre- and post-protocol.  
 


Background:

• Enoxaparin is commonly used for venous thromboembolism (VTE) prevention in acutely ill patients; however, low body weight may increase the risk of bleeding with standard dosing (40 mg daily). Low-dose enoxaparin (30 mg daily) has shown similar VTE prevention with lower bleeding rates. This study evaluates the impact of a pharmacist-initiated Pharmacy & Therapeutics (P&T) protocol on enoxaparin dosing adjustments in low body weight patients. 

Methods:

• This quasi-experimental study, approved by the institutional review board, included 205 patients from September 1, 2022, to September 1, 2024. The P&Tprotocol allowing pharmacists to reduce enoxaparin doses for low body weight patients was implemented on October 31, 2023. Inclusion criteria were patients aged ≥ 18 years, receiving either enoxaparin 30 mg twice daily or 40 mg daily, with a BMI ≤18 or body weight ≤45 kg. Exclusion criteria included Creatinine Clearance <30 mL/minute at the time of enoxaparin initiation (Cockroft-Gault using adjusted body weight), therapeutic anticoagulation indication, acute thrombus on admission, active bleeding on admission, pregnant or peripartum, admitted or transferred to any ICU service, platelets < 50,000 cells/microliter, and patients with neuraxial catheters.Patients were required to receive at least two doses of enoxaparin to be included. Pre- and post-protocol groups were compared in accordance with when the P&T protocol was implemented. The primary outcome was whether or not the enoxaparin dose was appropriately adjusted to the reduced dose. Secondary outcomes included the title of the person initiating dose changes, time until adjustment, and bleeding incidence (defined by ISTH criteria). 

Results:

• The analysis included 115 pre-protocol and 90 post-protocol encounters. The post-protocol group had significantly more appropriate enoxaparin dose adjustments to 30 mg daily (40 [33.0%] vs 75 [77.9%], p < 0.0001). Of those that received dose adjustments, pharmacists were the providers more commonly making dose adjustments (70 [77.9%] vs 4 [4.4%], p < 0.0001). The length of hospital stay was similar in both groups (4.9 days vs 5.2 days, p = 0.2582). There were no significant differences in the time to appropriate dosing (0 [0,0] days vs 0 [0,1] days, p = 0.0676). Additionally, there were no major differences ineither major (0% in pre-protocol vs 0% in post-protocol) or minor bleeding incidence (0% in pre-protocol vs 1.1% in post-protocol, p = 0.439) between the groups. 

Conclusions:

• A pharmacist-initiated P&T-approved dose-adjustment protocol resulted insignificantly more appropriate dose adjustments of enoxaparin by pharmacists, with no difference in bleeding events. The lack of bleeding events in either group may be a result of the low number of patients included in this study compared to other similar studies. The relatively short length of stay may also have contributed to the lack of bleeding events, as the follow-up period lasted only until hospital discharge; patients who experienced bleeding events after hospital discharge would not have had the event recorded in this study. Further study is needed with a larger sample size to fully understand the safety benefits of a pharmacist-initiated dose adjustment protocol of enoxaparin and whether such a protocol should be considered for broader implementation to enhance clinical outcomes in low body weight hospitalized patients at risk for VTE.

 

Title: Pre/Post Analysis of Vancomycin Dosing Guidance in Patients with Obesity in the Hospital Setting


Authors: Courtney Feagin, Kelly Gamble, Hannah Schmoock


Background: Pharmacokinetic data for patients with obesity is not readily available for most medications, and pharmacokinetic profiles vary greatly between patients making dosing difficult to standardize. Supratherapeutic doses of vancomycin can lead to nephrotoxicity and ototoxicity, thus leading to the need for close monitoring of vancomycin levels. Currently, there is limited guidance on vancomycin dosing recommendations in this population. The purpose of this study is to evaluate the effects of a vancomycin dosing in obesity guidance document on dosing efficacy and patient outcomes.  


Methods: This institutional review board approved, retrospective, single-center pre-post cohort study utilized an electronic list of adult patients hospitalized at McLeod Regional Medical Center between March 2024 and February 2025. The pre-group patients were evaluated between March 2024 and September 2024, and the post-group patients were evaluated between November 2024 and February 2025. Patients were included if they had a body mass index (BMI) of ≥ 30 kg/m2 on admission, received at least one dose of intravenous vancomycin, and had at least one vancomycin level drawn at steady state. Patients were excluded if they had baseline severe renal impairment (including acute kidney injury (AKI), hemodialysis, continuous renal replacement therapy, or peritoneal dialysis), pregnant or breastfeeding, reported an allergy to vancomycin, or if vancomycin was initiated at an outside institution. An internal guidance document was created by the infectious disease pharmacy team to aid with dosing vancomycin in patients with obesity, and it was presented to inpatient pharmacists during October 2024. Data was collected via an electronic, password protected spreadsheet accessible only to the primary study investigators. The primary outcome measured was the incidence of therapeutic doses of vancomycin according to target trough levels. Secondary outcomes measured were the incidence of obese patients receiving therapeutic doses of vancomycin according to target area under the curve (AUC) values, incidence of acute kidney injury (AKI), non-therapeutic trough levels at steady state, and non-therapeutic AUC values at steady state.    


Results: Overall, 905 patients were screened for inclusion: 597 patients in the pre-guidance document group and 308 patients in the post-guidance document group. In the pre-group, 550 patients were excluded, and 45 patients were included. In the post-group, 283 patients were excluded, and 23 patients were included.  The overall population is reflective of 61.8% (n=42/68) male, median age of 56 years old (interquartile range [IQR] 46 to 63), median BMI of 35.9 kg/m2 (IQR 32.3 to 41.4), and median Charleson Comorbidity Score of 2 (IQR 1 to 4). The primary outcome was seen in 26.7% (n=12/45) of patients in the pre-group and 34.8% (n=8/23) of patients in the post-group (p=0.49). Secondary outcomes in both groups are as follows: patients with AKI at 72 hours post discontinuation of vancomycin (17.8% vs. 21.7%, p=0.69), patients with a therapeutic AUC (60% vs. 56.5%, p=0.78), subtherapeutic trough level (35.6% vs. 30.4%, p=0.67), supratherapeutic trough level (37.8% vs. 34.8%, p=0.81), subtherapeutic AUC (17.8% vs. 17.4%, p=1.0), and supratherapeutic AUC (17.8% vs. 21.7%, p=0.72).  


Conclusion: This retrospective cohort study did not find that there was a statistically significant difference between patients whose vancomycin was dosed with or without implementation of a pharmacy dosing guidance document. However, this could have been impacted by many different factors that would need to be reevaluated in future studies. These strategies may include requiring use of the dosing guidance document, re-educating pharmacists on timing of troughs and using the guidance document, extending the study timeframe, and conducting the study after the national fluid shortage resolves.

Title: Impact of an Antibiotic Guide Paired with Audit and Feedback on Antipseudomonal Antibiotic Use in a Community Hospital


Authors: Olivia Bray, Linda Johnson


Objective: The purpose of this retrospective review is to evaluate the impact of the antimicrobial stewardship intervention in reducing the inappropriate use of piperacillin/tazobactam and cefepime when possible. 


Self Assessment Question: True / False - It is appropriate to use antipseudomonal antibiotic coverage in all patients with community-aquired gram-negative infections. 


Background: Overuse of broad spectrum antibiotics such as piperacillin/tazobactam and cefepime can lead to increased resistance and difficult to treat organisms. Our institution uses more piperacillin/tazobactam and cefepime than expected, with the majority of inappropriate use during the empiric phase of treatment. Based on this data, guidelines for appropriate use of piperacillin/tazobactam and cefepime were developed and distributed to providers. Furthermore, the antimicrobial stewardship pharmacist performed focused reviews and direct provider interventions Monday thru Friday to reduce inappropriate use. 


Methods: Adult patients admitted to the hosptial initiated on antibiotics for gram negative rod infections for at least 48 hours during November 2023 (pre-period) and November 2024 (post-period) were included. Patients were excluded if not being managed by the hospitalist service or admitted to intensive care units, adult step down units, or hematology/oncology units. Patients being managed by the infectious disease services were also excluded.


Results: In progress


Conclusion: In progress

TITLE:    Oral Vancomycin vs Fidaxomicin for Treatment of Initial Clostridioides Difficile Infection   
Olivia Hill, Marcus Mize, Serina Tart
BACKGROUND: The 2021 Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA/IDSA) Update to the Clinical Practice Guidelines for the Management of Clostridioides difficile infection (CDI) in Adults recommends oral (PO) fidaxomicin 200 milligrams (mg) twice daily for 10 days as the preferred therapy for an initial severe or non-severe CDI episode due to lower rates of recurrence.  Cost is a substantial barrier to fidaxomicin use and often leads to the utilization of PO vancomycin as the alternative initial treatment agent in practice. This research project aimed to evaluate the differences in treatment failure, rate of recurrence, and treatment cost between vancomycin and fidaxomicin for the treatment of initial CDI to provide additional information to help guide the choice between the two agents. 
METHODS: This multicenter, retrospective, observational cohort study examined patients with confirmed first occurrence of mild to severe CDI who were admitted to hospitals within the Cape Fear Valley Health System (CFVHS) from January 1, 2023, to December 31, 2023. Included patients were 18 years or older and had a confirmed CDI defined as positive antigen/toxin or PCR test. Patients were excluded if they had a fulminant or recurrent CDI, were actively being treated for other infections, or had received bezlotoxumab. The primary outcome assessed the differences in composite endpoint of treatment failure and/or 30-day recurrence rates in patients with documented first occurrence of CDI treated with vancomycin versus fidaxomicin. Secondary outcomes included differences in the rate of treatment failure and rate of 30-day recurrence between groups as well as differences in mean treatment cost between intensive care unit (ICU) setting versus medical/surgical floors.
RESULTS: Sixty-seven patients met inclusion criteria with 7 patients in the fidaxomicin group and 60 in the PO vancomycin group. The most common reason for exclusion was treatment for concurrent infections. Of patients included, 47.8% had community acquired CDI, 94.0% of patients had non-severe CDI, and 97.0% were admitted to a medical/surgical floor at the time of diagnosis. The average length of stay from time of diagnosis was 6.48 days. For the primary outcome, 7 (11.7%) patients in the vancomycin group experienced treatment failure or 30-day recurrence compared to 3 (42.9%) patients in the fidaxomicin group (p=0.0284). Treatment failure was experienced by 5 (8.3%) patients in the PO vancomycin group compared to 3 (42.9%) patients in the fidaxomicin group (p=0.0077). Recurrence at 30 days was experienced by 2 (3.3%) patients in the PO vancomycin group compared to 1 (14.3%) patient in the fidaxomicin group (p=0.1849). All fidaxomicin patients were located on a medical/surgical floor. The mean treatment cost for those in the PO vancomycin group was $8,752.05 (± $10,067.92) versus $7,148.09 (± $3239.33) in the fidaxomicin group, with a cost difference of $1603.96 (95% CI –2081.1 to 5289.0, p=0.7506). 
CONCLUSION: A limitation of this study was the lack of an adequate sample size in the fidaxomicin group which led to wide intergroup variability, making it difficult to draw conclusions. Within the PO vancomycin group, there were lower rates of treatment failure, 30-day recurrence, and 1-year recurrence compared to fidaxomicin. Although the results of this study are hypothesis-generating, it supports the idea that PO vancomycin could be utilized as a first-line option for initial CDI without increasing the risk of recurrence or treatment failure. More studies should be conducted to further analyze the potential for vancomycin’s place as a first-line agent for initial CDI.

EFFECTIVENESS OF PARTIAL VS. FULL-LEAD-IN APIXABAN IN ACUTE VTE AFTER INITIAL PARENTERAL THERAPY


Background: Apixaban, a direct oral anticoagulant (DOAC), is commonly used to treat venous thromboembolism (VTE). The AMPLIFY trial established a seven-day apixaban lead-in regimen following parenteral therapy for acute VTE treatment, but clinical practice often results in extended parenteral anticoagulation preceding apixaban exposure, creating uncertainty regarding optimal apixaban lead-in strategies. A partial lead-in regimen, where apixaban completes the full seven-day regimen including days of parenteral therapy, contrasts with the full lead-in regimen of seven days of apixaban regardless of prior parenteral treatment duration. The impact of these diverse strategies on bleeding and VTE recurrence risk is not well understood. This study aimed to evaluate whether a full apixaban lead-in regimen increases bleeding risk compared to a partial apixaban lead-in regimen in patients with VTE.


Methodology: This was a single-center, retrospective chart review of patients who were started on high dose apixaban 10 mg twice daily after more than 36 hours of parenteral anticoagulation for VTE treatment between August 2015 and September 2024. Patients were included in the full lead-in group if they were ordered 7 days of high dose apixaban after parenteral anticoagulation and patients were included in the partial lead-in group if they were ordered enough high dose apixaban doses to completed 7 full days of anticoagulation, started by the parenteral anticoagulants. The primary outcome was the incidence of major bleeding as defined by the ISTH guidelines. Secondary outcomes included non-major bleeding, readmission for bleeding, and medical contact for VTE recurrence or bleeding within 90 days. 


Results: 418 patients were screened and 61 were included in the study. A total of 58 patients were assigned to the full lead-in group and 8 patients to the partial lead-in group. The primary outcome of incidence of major bleeding was seen in 2 (3.8%) patients in the full lead-in group and 2 (25%) patients in the partial lead-in group (P= 0.247). The secondary outcome of readmission for bleeding was seen in 2 (3.8%) patients on the full lead-in group and 1 (12.5%) patient in the partial lead-in group (P=0.349). Medical contact for VTE recurrence or bleeding within 90 days was not present in either group. 


Conclusions: This study found that real world prescribing practices favors the full lead-in apixaban therapy dosing strategy. The full lead-in group did not show a higher rate of ISTH major bleeding. However, the small sample size, especially in the partial lead-in group, limits conclusions. Larger studies and randomized controlled trials are needed to establish the real safety and efficacy of these two dosing strategies.  

Title:
Evaluation of SGLT2 Inhibitor Effects on Glycemic Management in Hospitalized Non-Critically Ill Patients 
 
Authors: 
EJ Marineau, PharmD
Dennis Dubovetsky, PharmD
 
Background:
The American Association of Clinical Endocrinology (AACE) and American Diabetes Association (ADA) guidelines recommend the use of sodium-glucose co-transporter-2 inhibitors (SGLT2i) in patients with type 2 diabetes mellitus (T2DM) who either have established or are high-risk for atherosclerotic cardiovascular disease, heart failure (HF), or chronic kidney disease. ADA endorses use of SGLT2i in T2DM patients hospitalized with HF, while AACE and Endocrine society guidelines provide no guidance on SGLT2i role in hospitalized patient population. Only a handful of studies focused on evaluation and reported glycemic management outcomes and safety in hospitalized patients with T2DM receiving SGLT2i. Due to this increased inpatient use, additional data on safety and efficacy for glycemic management is warranted. The objective of this study was to assess the safety and efficacy of SGLT2i in the management of T2DM in non-critically ill hospitalized patients.
 
Methods:
This was a single-center, retrospective chart review conducted at AdventHealth Orlando. Patients were enrolled if they were at least 18 years of age and had an established history of T2DM.  Intervention group consisted of patients who received a SGLT2i plus multimodal insulin and compared to patients who received multimodal insulin alone. Primary objective evaluated difference in median blood glucoses.  Secondary objectives evaluated difference: percentage of blood glucose readings within target range (100 to 180 mg/dl), total insulin dose (units), 90-day all-cause readmission rate, inpatient mortality, rate of acute kidney injury, length of stay (days), percentage of patients with hypoglycemic events (less than 70 mg/dl), and rate of new onset ketoacidosis.
 
Results: 
A total of 150 patients met the inclusion criteria and were evenly distributed into each arm. There was a significant difference in the primary outcome of median blood glucose in favor of the SGLT2i arm (165 mg/dL) compared to the insulin alone arm (180 mg/dL, p<0.001). Patients in the SGLT2i arm received lower median total daily dose of insulin (15 versus 16 units, p=0.006). SGLT2i arm was associated with lower median number of 90-day readmissions (28 versus 48 p=0.005). There was no difference between the groups with respect to remaining safety secondary outcomes of inpatient mortality, length of stay, acute kidney injury, rates of hypoglycemic events and ketoacidosis (p=NS).

Conclusions:
In acutely ill hospitalized patients with T2DM treatment with SGLT2i in addition to standard care (multimodal insulin) was associated with overall lower blood glucose values, lower insulin requirements, and a lower rate of 90-day readmissions when compared to insulin only strategy. SGLT2i exposure was not associated with significant difference in other safety outcomes. Further studies are warranted to characterize safety and efficacy profile of SGLT2i as an option for inpatient glycemic management.

Title: Impact of Oral Antibiotics on Length of Stay in Patients with Gram-Negative Rod Bacteremia
 
Authors: Katlyn Womble, Marcus Mize, Serina Tart


Objective: To compare the length of hospital stay (LOS) in days in patients with gram-negative rod (GNR) bacteremia who are transitioned to oral antibiotics to complete treatment versus patients who receive intravenous (IV) antibiotics for the duration of therapy.


Methods: Eligible patients were those aged ≥18 years old, admitted to a hospital within the health system from January 2023 – December 2023 with documented GNR bacteremia, and received antibiotic therapy for ≥48 hours. Patients with polymicrobial infections, multi-drug resistant (MDR) or extended-spectrum beta-lactamase (ESBL) organisms, were unable to tolerate oral medications, had an infection or predisposing condition that would require IV therapy, or received >14 days of IV therapy were excluded. Data was collected through chart review on the electronic health record system. The primary outcome was the difference in LOS between patients who were transitioned to oral therapy compared to those who remained on IV therapy for the duration of treatment. Secondary outcomes included percentage of treatment failure in each group, the difference in total duration of antibiotic therapy between groups, and the difference in LOS between patients who were transitioned to oral therapy early (defined as ≤4 days from start of appropriate antibiotics) compared to those who were transitioned to oral therapy late.


Results: Of the 388 patients reviewed, 176 patients were excluded with the most common reason being polymicrobial infection. A total of 208 patients were included, with 168 being transitioned to oral antibiotics and 40 receiving IV antibiotics for the duration of therapy. Of those included, 65.4% were female and the average age was 64.9 years in the oral group, compared to 71.5 years in the IV group. Of those in the oral group, 11.9% had an indwelling device and 6% were immunocompromised, compared to 15% and 10% in the IV group, respectively. The majority of patients had a urinary infection source, with the most common isolated organism being Escherichia coli. The most common parenteral antibiotic administered was ceftriaxone, with most patients in the oral group being transitioned to cefdinir. The average length of stay was 18.7 (±17.3) days in the IV group, compared to 6.3 (±12.0) days in the oral group (95% CI -18.2 to -6.6, p < 0.0001). Average duration of therapy in the IV group was 11.4 (±3.0) days, compared to 13.0 (±3.0) days in the oral group (95% CI 0.53 to 2.65, p=0.0039). Among patients in the oral group, the average length of stay was 5.6 (±17.8) days in those transitioned to oral therapy early, compared to 6.9 (±4.0) days in those who were not (95% CI -5.6 to 3.0, p =0.5606).  Treatment failure was low in both groups, occurring in 4.2% patients in the oral group versus 10% in the full IV group (p = 0.1708).


Conclusions: Among patients with GNR bacteremia, those who were transitioned to oral antibiotics had a significantly shorter LOS compared to those remaining on IV therapy, although duration of therapy was significantly longer. Within the oral therapy group, LOS was significantly shorter in those transitioned to oral antibiotics early. Although the results of this study are descriptive, it further supports current evidence demonstrating that oral antibiotics may be effective in patients with uncomplicated GNR bacteremia and may shorten hospital LOS. Limitations of this study include the small number of patients who were immunocompromised or had indwelling devices, limiting application to these populations, and the small rate of treatment failure which prevents the outcome from being analyzed for statistical significance. More studies should be conducted to include broader patient populations and further analyze the effect that transitioning to oral antibiotics may have on treatment failure rates.

Title: Effect of Antidepressant Continuity on Analgosedation in Mechanically Ventilated Patients

Authors: Isabelle Perling, Sarah Blackwell, Kenda Germain, John Michael Herndon

Objective: Assess the effect of antidepressant continuity or discontinuity on analgosedation in mechanically ventilated patients. 

Self Assessment Question: True or False: Abrupt cessation of antidepressants can cause antidepressant discontinuation syndrome that typically occurs in patients using SSRI or SNRI medications with short half-lives.

Background: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first line treatment options for depression and anxiety and are used for many other psychiatric disorders. In critically ill patients with mental disorders, psychiatric symptoms may be heightened due to a change in environment and physical condition. Despite this, many antidepressants are not continued in the critical care setting for various reasons. Abrupt cessation of antidepressants can cause antidepressant discontinuation syndrome (ADS), with symptoms including agitation, mood changes, insomnia, dizziness, nausea, and vomiting. ADS has a mean onset of two days after discontinuation and is most common in patients using agents with short half-lives. The syndrome can mimic hyperactive intensive care unit (ICU) delirium, which may lead to increased sedative doses to maintain goal sedation, while the underlying cause is left untreated.

Methods: This is a single center, retrospective chart review in patients who were on SSRI or SNRI therapy prior to a hospitalization where they were subsequently intubated. Included patients were 18 years of age or older, receiving outpatient SSRI or SNRI therapy prior to hospitalization, and initiated on mechanical ventilation within 48 hours of admission. Patients with current substance abuse, need for deeper sedation, acute neurological events, chronic invasive mechanical ventilation, pregnancy, or incarceration were excluded. Patients who restarted SSRI or SNRI therapy between 49 and 72 hours were also excluded. Outcomes were compared between patients who resumed their SSRI or SNRI within 48 hours of intubation and patients for whom their SSRI or SNRI was held for more than 72 hours after intubation. The primary endpoint was the dose of IV analgosedation at 72 hours represented by the fraction of IV sedation score (FISS). FISS is a novel scoring system created to compare analgosedation medications and doses for patients on various agents. It is calculated by dividing the dose of each analgosedation agent by the typical maximum dose at the facility. Each of these are then added together to create the numerical FISS. Secondary endpoints included FISS at 24 and 48 hours, RASS at 24, 48, and 72 hours, ICU and hospital lengths of stay, duration of mechanical ventilation, and duration of IV analgosedation. Statistical tests included the student’s t-test and the Wilcoxon rank sum test.

Results: Forty patients were analyzed. FISS was similar between patients who continued their antidepressant and the discontinuity group at 72 hours post intubation, 0.95 ± 1.02 vs. 0.60 ± 0.66 (p = 0.194). There was no difference in FISS at 24 and 48 hours, RASS, ICU and hospital LOS, and duration of mechanical ventilation or analgosedation.

Conclusion: Antidepressant continuity did not result in a difference in analgosedation needs or other outcomes. The novel FISS offers a practical way to compare analgosedation needs across various agents but needs external validation for external use.

Contact information: isabelle.perling@orlandohealth.com

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

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

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

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

Title: Outcomes Associated with Formal Infectious Diseases Consultation for Positive Blood Cultures with Staphylococci Other Than Staphylococcus aureus 


Authors: Kellee B. Geren, Brandon Hawkins, Mary Joyce Wingler, Jessica Ortwine, Samantha Walker, Helen Ding, Bryan Walker, Cami Andreini 


Objective: This study attempted to determine the impact of infectious diseases consultation on the clinical management, readmission, and mortality of patients with Staphylococcus lugdunensis, Staphylococcus pseudintermedius, or Staphylococcus schleiferi isolated from a blood culture. 


Self Assessment Question: True or False: Infectious diseases consultation in patients with S. lugdunensis, S. pseudintermedius, or S. schleiferi bacteremia resulted in a significant decrease in mortality or 30-day readmission.


Background: There is data suggesting infections caused by S. lugdunensis, S. pseudintermedius, and S. schleiferi may be associated with a higher acuity of illness. However, there is limited data defining the management of these organisms when isolated from a blood culture, as well as the impact of infectious disease consultation on mortality in these patients.


Methods: This was a multi-center, observational, retrospective cohort study that compared the clinical management and disease course of patients with (consult group) and without an infectious diseases consultation (no consult group). Adult patients admitted between January 1, 2014 and March 1, 2024, with blood cultures positive for one of the specified organisms were included. Patients were excluded if S. aureus was isolated at any point during admission or if they discharged, died, or transitioned to hospice prior to blood culture speciation. 


Results: The primary outcome composite of 90-day all-cause mortality from index blood culture or 30-day readmission due to bloodstream infections caused by S. lugdunensis, S. pseudintermedius, or S. schleiferi was 17.9% in the no consult group and 12.2% in the consult group (p = 0.308). Hospital length of stay was a median of 6.82 days in the no consult group compared to a median of 11.69 days in the consult group (p < 0.001). Thirty-day mortality was 12.8% in the no consult group versus 8.5% in the consult group versus (p = 0.379). 


Conclusion: In patients who received an infectious diseases consult, 90-day mortality, 30-day mortality, and 30-day readmission were numerically, but not significantly, lower. A larger study is needed to assess the impact of infectious diseases consultation on mortality for specific staphylococci. 

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

Title: Description of Clinical Pharmacist Interventions on an Acute Care Unit
Authors: Jamarius Carvin, Kelley Frances Henley, Niaima Geresu, Irene Bemis, Kristina Evans, Stella Ye 
Objective: Evaluate the impact of a dedicated clinical pharmacist on acute care unit interventions 
Self-assessment: How did a dedicated pharmacist affect daily interventions? 
Background: In a clinical setting, pharmacists optimize medication therapy and enhance patient safety. Studies have shown pharmacists identify and prevent errors with potential cost avoidance. Quantifying their impact is crucial for justifying clinical pharmacy services, especially concerning medication errors at hospital discharge, which pose risks and increase costs. Pharmacist-led medication reconciliation at discharge (PMRD) has shown positive impacts on reducing medication errors, preventing adverse drug events and improving patient safety. Pharmacists also provide drug information, optimize therapy, and improve cost-effectiveness. It is important to continue to evaluate the impact of a clinical pharmacist in an evolving healthcare field, so this research investigates the impact of implementing a dedicated clinical pharmacist on an acute care unit by quantifying interventions. 


Methods: This retrospective chart review was conducted at Grady Health System (GHS). The study compared two periods on a 40-bed acute care unit: a baseline period (20 weekdays in April 2024) with usual GHS pharmacy protocol and an intervention period (20 weekdays from May-June 2024) with a dedicated pharmacy resident. The primary outcome was the average number of pharmacist interventions per day. Secondary outcomes included intervention categorization, the number of patients with interventions, the total number of interventions, and high-risk medication interventions. Exclusion criteria were duplicate documented interventions. Descriptive statistics and chi-squared testing were used for analysis. 


Results: The average number of interventions per day increased from 5.7 (± 2.6) in the control period to 16.85 (± 7.8) in the intervention period. The total number of documented interventions in the control period was 99 compared to 337 in the intervention period.  The number of patients with at least one documented pharmacist intervention increased from 61 to 175

Title: 
Evaluation of Quality Measure Outcome Adherence in the Treatment of Spontaneous Bacterial Peritonitis in Patients at a Large Community Hospital

Authors:
Leeann Gowan, Christen Freeman, Doug Carroll

Objective:
Discuss adherence to quality measure outcome set forth by the American Association for the Study of Liver Diseases (AASLD) for the treatment of spontaneous bacterial peritonitis.

Self Assessment Question:
What is the recommended albumin dose patients treated for SBP should receive within 12 hours of the ascitic fluid test result?

Background: 
Spontaneous Bacterial Peritonitis (SBP) is an ascitic fluid infection with an unknown source of origin. This infection is one of many complications resulting from advanced liver cirrhosis and ascites. As recommended by the American Association for the Study of Liver Diseases (AASLD) practice guidance, a diagnostic paracentesis should be performed on all patients with suspected SBP. Management of SBP includes the use of antibiotics and albumin. Empiric IV antibiotics should be initiated in all patients with an ascites polymorphonuclear (PMN) count >250 cells/mm3. 

Furthermore, patients with cirrhosis have an increased risk of worsening liver and renal function from bacterial infections. The appropriateness of treatment of SBP has not been assessed at DCH. Consequently, this is a disease state, that if quality measures are not met, can progress to high rates of mortality and worsening liver and renal function. The purpose of this study was to evaluate percentage adherence to a specific cirrhosis quality measure set forth by the Practice Committee of the AASLD, in the treatment of SBP in patients at DCH Regional Medical Center and Northport Medical Center.

Methods:
This was a retrospective chart review of patients treated for SBP at DCH Regional Medical Center (a large community 583-bed hospital) and Northport Medical Center (a 204-bed community hospital). Patients were included if they were 19 years old or older, had an ICD-10 diagnosis of cirrhosis and ascites and SBP or had an ascitic fluid PMN count >250 cells/mm3. 

A list of patient encounters was generated from the electronic health record (EHR) from May 2021 to July 2024. Patients that were selected for review first, were those with an ICD-10 diagnosis code for SBP, then those with an ascitic fluid white blood cell count (WBC) count. A PMN count was calculated by multiplying the total WBC by the percentage of PMNs in the differential (neutrophils). The primary outcome measure was percentage adherence to meeting all 3 criteria of the guideline recommended quality measure outcome: hospitalized patients with ascites, with an ascitic fluid PMN count of ≥ 250 cells/mm3, should receive: empiric antibiotics and albumin 1.5 g/kg within 12 hours of the ascitic fluid test result and receive albumin 1.0 g/kg on day 3. Secondary outcomes were comparison of results for those with a GI consult, characterization of antibiotic regimen, and patient encounter mortality rate. For the statistical analysis, descriptive statistics were utilized. This study was IRB exempt.

Results:
This study included a total of 40 patients. Overall, there were zero patients that met all 3 criteria of the quality measure outcome. Twenty-eight patients met at least one criteria (70%). Patients with a GI consult overall had improved outcomes. Twelve patients were empirically treated with a 3rd generation cephalosporin (54.5%). Five patients (22.7%) were treated for 5-7 days out of the twenty-two patients only treated for SBP.

Conclusion:
This study observed many ways to improve treatment of SBP at DCH. Areas of improvement include correct albumin dosing, administration of albumin within the 12-hour range, and administration of the second dose of albumin on day 3.

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


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


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


Results: In-Progress


Conclusion: In-Progress

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


Authors: Dion Blocker, Michelle Marbury, Mariam Agbe


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


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


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

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

Title: Rates of Gastrointestinal Bleeding (GIB) in Patients Taking Concomitant Dual Antiplatelet Therapy (DAPT) and SSRI/SNRI Therapy Within One Year of Acute Coronary Syndrome (ACS) 
 
Authors: Hannah Holbert, Thaddeus McGiness, A. Shaun Rowe, Travis Fleming


Objective: Evaluate potential gastrointestinal bleeding risk associated with combined SSRI/SNRI and DAPT in patients receiving these medications for twelve months post-ACS.


Self-Assessment Question: Which of the following was associated with increased rates of GIB in patients at 12 months post-ACS?  a. Aspirin + prasugrel + duloxetine; b. Aspirin + prasugrel + sertraline; c. Aspirin + clopidogrel + venlafaxine; d. Aspirin + ticagrelor + fluoxetine; e. None of the above  


Background: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) modulate serotonin, which promotes mood enhancement in the central nervous system (CNS) and hemostasis in the peripheral nervous system (PNS). Inhibition of serotonin reuptake in the CNS increases emotional stability, making SSRIs and SNRIs useful antidepressants. In the PNS, these drugs prevent serotonin-mediated platelet aggregation, increasing bleeding risk. Because depression is common following major adverse cardiovascular events, there is a potential for patients to take concomitant SSRI or SNRI therapy with dual antiplatelet therapy (DAPT) for 12 months post-percutaneous intervention. The purpose of this study was to evaluate if patients receiving this combination were at a greater risk of gastrointestinal bleeding due to multiple antiplatelet mechanisms compared to those receiving DAPT alone. 
 
Methods: This single center retrospective cohort study included adult patients diagnosed with acute coronary syndrome (ACS) and treated with percutaneous intervention, stent implantation, and DAPT between January 1, 2014, to January 1, 2024. Patients were excluded from this study if they received DAPT for any indication other than ACS (e.g., ischemic stroke), if they had a previous diagnosis of cirrhosis, Helicobacter pylori infection, or cancer of the gastrointestinal tract, or if any of the following medications were on their discharge medication list: anticoagulants, systemic steroids, systemic non-steroidal anti-inflammatory drugs (NSAIDs), ginseng, garlic, ginkgo, or vitamin E. The primary outcome of this study was rates of gastrointestinal bleeding within 12 months of ACS diagnosis. Additional secondary outcomes included length of stay, therapy modifications at discharge, and 30-day and 90-day readmission rates.
 
Results: The primary outcome was observed in five patients (3%) in the DAPT group and no patients in the DAPT plus SSRI or SNRI group (P = 0.336). Readmission at 30 days occurred in 23 patients (13.6%) in the DAPT group and 10 patients (17.9%) in the DAPT plus SSRI or SNRI group (P = 0.436). Patients who were readmitted within 90 days of ACS discharge included 37 patients (21.9%) and 19 patients (33.9%) in the DAPT and DAPT plus SSRI or SNRI group, respectively (P = 0.071). There was no statistical difference between median length of stay between the two groups (P = 0.430). One notable baseline characteristic was a documented history of coronary artery disease (CAD). In the DAPT only group, the majority (106 patients; 62.7%) did not have a prior history of CAD, whereas 37 patients (66.1%) in the DAPT plus SSRI or SNRI group did have a documented history of CAD. This finding regarding past medical history of CAD was statistically different between both groups (P < 0.001). 
 
Conclusion: This study found no statistical difference in the rate of GIB in patients who received DAPT compared to those who received DAPT plus an SSRI or SNRI post-ACS. A statistical difference was observed, however, when comparing SSRI or SNRI use in patients based on prior history of CAD. Because patients with a prior history of CAD were more likely to take SSRIs or SNRIs, this study further endorses the use of these agents to treat secondary mental health disorders following ACS. Additionally, none of the patients in this study population who were taking SSRIs or SNRIs experienced a GIB, implying that use of these antidepressants could be considered both effective and safe in this population. More research should be conducted to further evaluate if the use of SSRIs or SNRIs in patients receiving DAPT for one-year post-ACS  impacts rates of bleeding events, especially in women, racial minorities, patients who underwent elective PCIs, and patients who experienced other types of bleeding events.   

Title: Impact of Hyperglycemia Education on Blood Glucose Control
Authors: Maegan Huebner, Kaitlyn Claybrook, Martina Goings, Danna Nelson 
Objective: To evaluate the impact of provider hyperglycemia management education at Baptist Medical Center South through its effect on inpatient glucose control. 
Background: Hyperglycemia in hospitalized patients, defined as a serum blood glucose level greater than 140 mg/dL, is a common occurrence in acutely ill patients. The American Diabetes Association (ADA) currently recommends the use of insulin as the preferred treatment for hyperglycemia in the inpatient setting. Basal or basal plus bolus regimens are preferred, while prolonged sliding scale as sole hyperglycemia treatment is not recommended. Recommendations for maintaining blood glucose less than 180 mg/dL and tailoring insulin regimens around patient enteral intake can improve outcomes, shorten patient length of stay, and reduce readmission rates. To increase adherence to ADA guidelines, physician groups including family medical residents, general medicine residents, and hospitalists from Baptist Medical Center South received a 30 minute interactive presentation on hyperglycemia management.
Methods: This is a retrospective chart review of pre and post physician education for patients who had an order for sliding scale insulin and a serum blood glucose level greater than 200 mg/dL. Patients excluded were those less than 19 years old, prisoners, patients with a singular increased blood glucose level, patients admitted for diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), patients with an insulin pump, those requiring a continuous insulin infusion, and pregnancy. Pre-education data was collected and analyzed in June 2024 and post-education data was collected and analyzed in October 2024. Information collected on the selected patients included demographics, length of stay, ordering physician, blood glucose levels, hypoglycemia events, A1c, insulin regimens while hospitalized, and any other oral anti-diabetic medications used. 
Results: After randomization, a total of 40 pre-implementation patients and 75 post-implementation
patients were reviewed and included. For the pre-implementation group, the average length of stay was 14.01 days, 25% experienced a hypoglycemia event, and the average blood glucose was 189.7 mg/dL. The average starting dose for insulin glargine was 10 units per day. The amount of time blood glucose levels were >200 mg/dL was 39.8%. For the post-implementation group, the average length of stay was 17.03 days, 36% experienced a hypoglycemia event, and the average blood glucose was 176.2 mg/dL. The amount of time blood glucose levels were >200 mg/dL was 28.9%. The average starting dose for insulin glargine was 17 units per day. All patients had a sliding scale insulin order besides one patient in the post-implementation group. The most common sliding scale order was written for level 1. 
 
Conclusion: The post-implementation group demonstrated a reduction in the time blood glucose levels were greater than 200 mg/dL, but higher rates of hypoglycemia were also observed. These effects may have been impacted by differences among the study group numbers and patient demographics. The post-implementation group was observed to receive a higher average starting dose of insulin glargine. Providing guideline-based hyperglycemia education to physicians resulted in improved blood glucose control but did not significantly impact hospital length of stay.
 

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

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

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

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

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

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

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

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

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

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

Title: Safety and Efficacy of Direct-acting Oral Anticoagulants versus Warfarin in the Treatment of Venous Thromboembolism in Severely Obese Patients


Authors: Olukemi Omotola, Madeline Shepherd, Evelyn Grafton


Objective: This study aims to compare the efficacy and safety of DOACs, particularly apixaban and rivaroxaban, versus warfarin in patients with severe obesity diagnosed with VTE.


Background: Venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), is a serious and potentially life-threatening condition. Anticoagulation therapy is the cornerstone of treatment for VTE to prevent clot progression, recurrence, and associated complications. Traditionally, warfarin has been the mainstay of treatment; however, direct-acting oral anticoagulants (DOACs), such as apixaban and rivaroxaban, have gained widespread use. In contrast to warfarin, their fixed dosing, fewer drug interactions, and lack of routine laboratory monitoring requirements make DOACs an appealing alternative. In the general population, DOACs have demonstrated non-inferior or superior efficacy and safety profiles compared to warfarin for the treatment of VTE. However, data is limited regarding their use in patients with severe obesity, defined as a body mass index (BMI) ≥ 40 kg/m². Given the growing prevalence of obesity, determining the safest and most effective anticoagulation strategies in this population is critical. 


Methods: This was a retrospective chart review of adult patients with a BMI of > 40 kg/m2 who received either apixaban, rivaroxaban, or warfarin for the treatment of venous thromboembolism from January 1, 2019 to September 30, 2024. Patients were excluded if they were pregnant or breastfeeding, had known hypersensitivity or contraindications to one of the study drugs, experienced active bleeding within 6 months of the start of the study time frame, had a history of a known hypercoagulable state, or if they received a fibrinolytic, mechanical thrombectomy, or underwent EkoSonic endovascular system (EKOS) procedure. The primary endpoint was VTE recurrence within one year. Secondary endpoints included major bleeding occurrence, clinically relevant non-major bleeding (as defined by the International Society of Thrombosis and Hemostasis), and all-cause mortality at one year. 


Results: The study included 76 patients, with 60 in the DOAC group and 16 in the warfarin group. For the primary outcome, 6 patients (10%) in the DOAC group experienced VTE recurrence versus 2 patients (12.5%) in the warfarin group (p=0.3186).  In the DOAC group, 3 patients (5%) experienced a major bleeding event, compared to 1 patient (6.3%) in the warfarin group (p= 0.4268). Two patients (3.3%) in the DOAC group experienced clinically relevant non-major bleeding, while no patients in the warfarin group had this type of bleeding event (p= 0.6211).  Finally, in the DOAC group, there were no reported deaths, while in the warfarin group, 2 patients (12.5%) died (p= 0.0421), making this the only statistically significant finding in the study.


Conclusion: DOACs are a safe and effective alternative to warfarin for treating VTE in severely obese patients. Given their comparable efficacy and lower all-cause mortality, DOACs may be a preferred choice in clinical practice.

Title: Blood Glucose Control in Post-Coronary Artery Bypass Graft (CABG) Patients


Authors: Elise M. Richoux, Leslie A. Hamilton, Heather Wallhauser, Rachael Samples, Taylor Bird, Robert E. Heidel, Travis Fleming


Objective: The objective of this study was to evaluate the median of time within goal blood glucose range following CABG surgery while receiving a continuous insulin infusion in groups before and after an insulin protocol change.


Presentation Objective: Evaluate the impact and incidence of goal blood glucose attainment in patients post-CABG on a continuous insulin infusion before and after an insulin protocol change.


Self Assessment Question: Which statement best describes the impact of hyperglycemia during and after cardiac surgery?
 
Background: Hyperglycemia following cardiac procedures is common. This is likely due to surgical stress triggering catecholamine and cortisol release, along with intraoperative hypothermia induced during cardiopulmonary bypass, which stimulates sympathetic activity. Elevated blood glucose levels during the intra-operative and post-operative period of cardiac surgery is associated with an increased risk of mortality in patients with and without diabetes as well as prolonged ventilator times, atrial fibrillation, and delirium. Controlling blood glucose levels can mitigate consequences such as prolonged ventilation, delayed sternal wound healing, and risk of mortality in patients with and without diabetes. Existing literature has inconsistency in blood glucose targets relative to observed outcomes, prompting consideration of the optimal level of glycemic control for post-CABG patients. More recently, the Society of Thoracic Surgeons (STS) published consensus statements on perioperative cardiac care which included a goal blood glucose range of 140-180mg/dL once an insulin infusion is initated. A protocol change implemented in August 2023 for cardiothoracic surgery patients replaced the previous insulin drip titration method, based on a multiplier and a blood glucose goal of 110-139 mg

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

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

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

Title: Pharmacist Impact on Inpatient Guideline-Directed Medical Therapy Prescribing in Heart Failure with Reduced Ejection Fraction


Authors: Hayley Harrod-Meeks, Kyle Starling, Hunter McDowell 


Objective: This project aimed to evaluate the impact of pharmacist intervention on inpatient prescribing of HFrEF GDMT at Atrium Health Navicent (AHN).


Self Assessment Question: True or False: Pharmacist intervention can increase inpatient prescribing of HFrEF GDMT?


Background: Heart failure with reduced ejection fraction (HFrEF) is a serious condition associated with high morbidity and mortality. The American Heart Association (AHA) guidelines recommend four classes of medications to reduce these risks: renin-angiotensin-aldosterone system (RAAS) inhibitors, beta blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose co-transporter 2 (SGLT-2) inhibitors. However, hesitancy to initiate or adjust these medications during hospitalization due to transient hypotension or acute kidney injury may worsen patient outcomes. We hypothesize that pharmacists play a key role in improving inpatient guideline-directed medical therapy (GDMT) prescribing. 


Methods: This was a pre-post study that involved physician education and pharmacist intervention. Prior to the intervention period, a brief educational guide on HFrEF GDMT was provided to hospital physicians. During the intervention period, patient chart reviews were conducted to make appropriate recommendations to physicians and to determine outcomes. Patients were included in the analysis if they met all four of the following criteria: were 18 years-old or older, admitted to AHN, had an ejection fraction less than 40%, and had an EPIC-calculated readmission risk score of at least 20%. Key exclusion criteria included patients requiring renal replacement therapy at discharge or those who died during hospital admission. The primary outcome was the percentage of patients discharged on each eligible pillar of GDMT. Secondary outcomes included the percentage of patients discharged on each individual GDMT pillar and the percentage of patients readmitted to AHN within 30 days of discharge. Chi-square analysis was performed to assess differences in outcomes. 


Results: In the intervention group, 24% of patients met the primary outcome while only 12% of baseline patients were discharged on all eligible GDMT pillars of HFrEF (P=0.023). Out of each medication class, the MRAs and SGLT-2 inhibitors were the least commonly prescribed in both groups. However, prescribing of both MRAs and SGLT-2 inhibitors was statistically higher in the intervention group, with a 16.3% increase in MRA prescribing (P=0.014) and a 14.6% increase in SGLT-2 inhibitor prescribing (P=0.031). Thirty-day readmission rates were reduced by 7.7% in the intervention group, though this was not statistically significant (P=0.244). 


Conclusion: In this pre-post study, we found that pharmacist intervention can significantly increase inpatient HFrEF GDMT prescribing, especially by increasing the prescribing of MRAs and SGLT-2 inhibitors. 30-day readmission rates also trended down in the intervention group, though not significantly. Key limitations in this study included physician turnover and hesitancy to change HFrEF regimens when an acute heart failure exacerbation was not the patient’s primary problem. Overall, this study showed that pharmacists play a key role in helping improve inpatient HFreF GDMT prescribing.  

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


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


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


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


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


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


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


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