2025 Southeastern Residency Conference

Title: Evaluation of Maintenance-and-Reliever Therapy Utilization for Pediatric Asthma 

Authors: Chiara Huber, Christina Cox, Katie Rasmussen, Kimberly Grubbs, Logan Miller, Heather Staples

Background: Asthma is the most common pediatric chronic condition, affecting over 4.5 million children. Prior to guideline updates, the standard approach to moderate to severe asthma in children included a short acting beta agonist (SABA) inhaler for relief of asthma symptoms, plus a separate inhaled corticosteroid (ICS) or ICS/long-acting beta agonist (LABA) inhaler for maintenance therapy. In 2019-2020, the Global Initiative for Asthma (GINA) and National Heart Lung and Blood Institute (NHLBI) asthma guidelines were updated to recommend the use of combination ICS-formoterol as both maintenance and reliever therapy (MART) as a preferred regimen in moderate to severe asthma in adults and children ≥ 5 years old. Despite new recommendations, a recent evaluation of MART use in adults found low adoption rates among eligible patients. Factors associated with MART adoptions included baseline maintenance use of ICS-formoterol, private insurance, younger patients and newer clinicians. Since limited information exists for pediatric patients, this study aims to describe MART implementation in pediatric asthma patients and identify the factors associated with MART recommendations.   

Methods: This retrospective cohort study included patients aged 5-18 with asthma who were admitted to Prisma Health Children’s Hospital-Midlands for an asthma exacerbation between January 1, 2022, and July 1, 2023. The primary outcome was the proportion of patients who qualified for MART and received a MART recommendation. For the purposes of this study, patients qualified for MART if they were utilizing an ICS or ICS/LABA inhaler at time of admission and had received at least one course of non-inhaled corticosteroids in the last year. Secondary outcomes included asthma readmissions within one year and an evaluation of factors that may be associated with MART recommendations. Statistical analysis will involve descriptive statistics and a multivariate regression analysis to assess the relationship between demographic data and MART therapy. 

Results: 598 patients were screened for enrollment and 246 were included in the primary analysis. The median patient age was 8 years, 69.5% of patients were Black, and 63.5% of patients were on Medicaid. 102 patients qualified for MART based on study criteria, however only 4 patients (3.9%)  were discharged with MART recommendations. 36 patients were readmitted for asthma within one year. Compared to those who did not qualify, patients who qualified for MART were more likely to be readmitted for asthma (21.6% vs 9.7%) and have a high risk disease state (14.7% vs 9.7%).

Conclusions: MART utilization remained very long among qualifying patients. Patients who qualified for MART had high rates of asthma readmissions and more frequently had disease states associated with higher exacerbation risk. 

A PROFILE OF DIRECT PURCHASING
Lauren Flick, Abbi Rowe

Background: For many health systems, almost the entirety of the drug inventory is purchased “indirectly” through a wholesale partner. This traditional model allows for streamlined access to a variety of products, provides an easy-to-use and regulatorily compliant ordering process, offers quick and consistent logistics, and is able to facilitate smaller, single unit of sale purchases. However, for health systems with the appropriate infrastructure, establishing direct purchasing relationships can be beneficial. AdventHealth’s Central Florida Division includes a Central Fill Pharmacy (CFP) that supplies drugs daily via an internal courier service to 18 acute care facilities within the division. CFP is located at an offsite warehouse space with roughly 15,000 square feet of medication storage space, allowing for pallet storage of bulk medication purchases.  This system provides advantages based on the volume of medications purchased, as well as storage solutions for larger orders, which can be leveraged when optimizing cost savings though alternate purchasing streams.

Purpose: Evaluate historic direct medication purchasing trends for process optimization opportunities.

Methods: Direct purchasing data from the CFP facility was compiled using historic invoices and logged in an Excel spreadsheet. All direct commercial medication purchases made from 3 September 2021 to December 2024 by CFP were included. Supplies and 503B purchases were excluded. The invoice date, medication description, NDC, quantity purchased, average blended price available at the wholesaler at the time of purchase, and direct price [LF1] were all recorded. Descriptive analysis of the data, including counts of unique molecules and NDCs, averages of cost savings and quantities purchased, and various pivots of the historic data was performed using Excel. Data visualization charts were created to display the findings and begin development of a comprehensive dashboard for ongoing tracking and optimization of direct pharmacy purchasing.

Results: A total of 757 historic transactions were included in the analysis, with the highest number (n = 353) occurring in 2023.  While the median amount spent per order fluctuated between years ($8,462 in 2021, $9,600 in 2022, $7,150 in 2023, and $7,725 in 2024) the median savings per order decreased each year; from $5,600 in 2021 to $1,944 in 2024.  This suggests a willingness to complete purchases with smaller cost reductions associated with them, which could be related to familiarity and comfort with the process reducing the time investment required.  The largest percent of savings from a single drug came from dexmedetomidine, which accounted for 12.43% of total savings. Heparin, which had the highest number of total units purchased at 413,000 units, accounted for 5.88% of savings, and enoxaparin, which had the most purchases (158) and NDCs (21) accounted for 5.25%.  The drug class with the highest portion of savings was antimicrobials, with 35.32% of overall spendings, followed by cardiovascular drugs, which had the highest number of buys (261), NDCs (55), and individual units (973,006) and accounted for 28.49% of savings.  For analysis of purchasing source, Medigi was the highest in number of buys (399), maximum saving percent (86.5%), NDCs (133), and total units purchased (1,631,072), and accounted for 60.70% of total savings.

Conclusions: Direct purchasing is capable of sufficient procurement cost reduction for AdventHealth Central Fill Pharmacy to continue with the process.  While a few purchases of high-discount drugs can have result in large per-transaction savings, most of the accumulated savings over time comes from lower rates of savings on commonly purchased drugs.  Optimizing this process has the potential to allow for greater cost reduction in the future.

Title: Association Between Time-To-Therapeutic Tacrolimus Concentrations and Acute Rejection Following Heart and Kidney Transplant

Authors: Raymond Lin, Kwame Asare, Victoria Burnette

Introduction: Available evidence illustrates that greater time-in-therapeutic range tacrolimus therapy correlates with less acute rejection. There is minimal available evidence demonstrating that faster achievement of therapeutic tacrolimus concentrations is associated with better outcomes in terms of graft rejection and graft loss. Patients are at the highest risk of acute allograft rejection during the first 6 months post-transplant, necessitating more intense immunosuppression early on after transplant. This intense immunosuppression puts patients at risk for opportunistic infections such as Pneumocystis jirovecii pneumonia (PJP), cytomegalovirus (CMV), urinary tract infections (UTI), BK virus, etc. Tacrolimus is the first-line calcineurin inhibitor due to superior efficacy compared to cyclosporine. Major adverse events include nephrotoxicity, and neurotoxicity (seizures, tremors, paresthesias, headache, PRES, AMS). The purpose of this study was to evaluate incidence of biopsy proven acute rejection (BPAR) and/or graft failure in patients who achieved therapeutic tacrolimus concentrations <10 days after medication initiation compared to patients who achieved therapeutic tacrolimus concentrations >10 days after medication initiation.

Methods: This study was a single center, retrospective chart review of adult patients admitted to Ascension Saint Thomas Hospital West (ASTHW) for heart and/or kidney transplant who received tacrolimus as part of maintenance immunosuppression between August 1, 2022 and September 1, 2023. Patients who were pregnant or incarcerated were excluded. Patients were divided into two groups based on the time-to-therapeutic range tacrolimus concentrations following treatment initiation: < 10 days or > 10 days. The primary outcome was incidence of  BPAR and/or graft failure <6 months following heart and/or kidney transplantation. Secondary outcomes included incidence of infection, neurotoxicity, nephrotoxicity, and hospital readmission at 6 months post-transplant.

Results: A total of 99 patients were included in our analysis, of whom 48 were stratified into the achieved therapeutic tacrolimus concentrations  <10 days after medication initiation group and 51 into the achieved therapeutic tacrolimus concentrations >10 days after medication initiation group. The primary outcome of BPAR and/or graft failure occurred in 10 (10%) patients, with 4 patients in the <10 days group and 6 patients in the >10 days group (P= 0.74). There were no statistically significant differences between the groups in occurrence of CMV (8% vs. 8%, P> 0.99), UTI (8% vs. 16%, P= 0.359), BK virus (4% vs. 2%, P= 0.61), other treated bacterial, viral, or fungal infections (33% vs. 25%, P= 0.392), tremor (29% vs. 24%, P= 0.524), acute kidney injury (54% vs. 65%, P= 0.286), or readmission at 6 months (33% vs. 33%, P> 0.99).

Conclusion: In this study of kidney and/or heart transplant recipients receiving tacrolimus as maintenance immunosuppression, there were no statistically significant differences in rates of BPAR and/or graft failure, infection, neurotoxicity, nephrotoxicity, or readmission. Future studies evaluating time-to-therapeutic range should consider the varying time-in-therapeutic ranges.

Owen C. Bradford, PharmD, MSN
Birmingham VA Health Care System
700 19th St. S - Birmingham, AL 35233
Owen.Bradford@VA.gov
 
Title:
Evaluation of a Clinical Pharmacist-Led Service to Facilitate Transitions of Care for COPD within an Integrated VA Healthcare System
 
Authors:
Owen C. Bradford
Whitney White 
Caitlin Brown
 
Background/Objective: 
Previous implementations of pharmacist-led transitions of care services have shown improvement in clinical and economic outcomes across numerous disease states. Although chronic obstructive pulmonary disease (COPD) is a progressive disease state, COPD-related morbidity is largely modifiable through optimal medication utilization and adherence. The objective of this study is to evaluate a new clinical pharmacist-led COPD transitions of care service within an integrated VA healthcare system in order to determine its impact on utilization of guideline-directed medication therapy and associated measures. 
 
Methods:
This QI study will evaluate data from hospital follow-up visits for patients admitted with a diagnosis of a COPD exacerbation. Patients will be identified based on referral before hospital discharge. Post-discharge follow-up visits will be conducted via telephone, video, or face-to-face format. 
A retrospective chart review will be performed to collect data related to completion of pharmacist interventions as well as clinical and economic outcomes. Pharmacist interventions may include successful medication reconciliation, patient education, modification of COPD pharmacotherapy, actions related to vaccination status or smoking status, etc. Clinical measures may include utilization of guideline-directed medication therapy, CAT and mMRC scores, smoking cessation status, and vaccination status. Economic measures may include formulary status of COPD therapies, total monthly cost of COPD therapies, etc. 
These measures will serve as the data source for determining primary and secondary endpoint results. The primary endpoint for this study will be the change in utilization of guideline-directed medication therapy (GDMT). Secondary endpoints will include change in CAT scores, change in mMRC scores, and change in vaccination status.
 
Results
A total of 7 patients were included during the study period (December 2024 through March 2025). All 7 patients were classified as GOLD group E based on hospitalization for exacerbation. The average time from hospital discharge to initial follow-up visit was 36 days. During these visits, pharmacists completed interventions including medication reconciliation, patient education, pharmacotherapy optimization, and actions related to smoking cessation and vaccination. Following these visits, adherence to guideline-directed medication therapy (GDMT) improved from 4/7 patients (57%) to 7/7 patients (100%). Of the 5 patients who were not up-to-date on recommended vaccinations, all were offered vaccination. 1 patient received the RSV vaccine during the visit, 1 denied all vaccinations, and 2 preferred to follow up with their primary care provider for vaccination. Four patients were identified as candidates for smoking cessation interventions. All 4 of these patients received counseling on smoking cessation, and 2 initiated or continued on nicotine replacement therapy. The average 30-day cost of pharmacotherapy increased from $48.87 to $66.28, which was attributed to the addition of guideline-driven COPD therapies. Formulary adherence remained 100% both pre- and post-visit.

Conclusion:
The implementation of this pharmacist-led transitions of care service for patients hospitalized with COPD exacerbations led to improved adherence to GDMT and enhanced delivery of preventive care. Pharmacist-led clinical interventions have the potential to positively impact long-term patient outcomes, including symptom control and reduction in hospital readmissions. While the small sample size limits broader application, this pilot demonstrates the feasibility and potential clinical and economic value of integrating pharmacists into transitions of care services for COPD management in the VA setting.
 
 

Title: Impact of dapagliflozin versus empagliflozin on renal function and diuretic response in patients with acute decompensated heart failure at a tertiary care community teaching hospital.


Authors: Principle Investigator's name and department: Manderrious Glenn, PharmD PGY1 Pharmacy Resident, Wellstar Cobb Medical Center | Co-Investigator: Jaleesa Myers, PharmD, BCPS, BCCP Clinical Pharmacist, Wellstar Cobb Medical Center


Objective: To compare the diuretic response in patients with acute decompensated heart failure (ADHF) receiving dapagliflozin or empagliflozin.


Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have established efficacy and are standard of care in the treatment of chronic heart failure (HF). However, limited data exists comparing their effects on diuretic response and renal function in ADHF. Inadequate diuretic response in ADHF is associated with poor outcomes, and specific recommendations regarding the use of SGLT2is in this context are scarce. The purpose of this study is to compare the diuretic efficiency and safety of dapagliflozin versus empagliflozin in ADHF to address this gap in clinical knowledge. 


Methods: This retrospective, observational cohort study was performed to evaluate the trends in diuretic response and renal function in patients with ADHF. Patients admitted to Wellstar Cobb Medical Center between May 1, 2023, and May 1, 2024, with a diagnosis of ADHF, age ≥18 years, and received either empagliflozin or dapagliflozin within 24 hours of hospitalization were included. Patients with systemic infection, end-stage renal disease on dialysis and not receiving diuretics, or hemodynamic instability were excluded. Data was collected on the first 100 patients to meet inclusion criteria within the specified time period. The primary outcome was diuretic response, defined as the change in weight in kg/[(total intravenous dose)/40 mg + (total oral dose)/80 mg furosemide or equivalent loop diuretic dose]. Secondary outcomes that were evaluated include length of hospital stay, incidence of worsening HF, incidence of worsening renal function, and 30-day mortality and readmission rates. Data was analyzed using t-tests for continuous variables and chi-square tests for categorical variables.  


Results: The median diuretic response was 0.62 for dapagliflozin and 0.68 for empagliflozin (p=0.31), indicating no significant difference between the two agents. Secondary outcomes, including length of hospital stay (8.5 vs. 8.6 days, p=0.98), 30-day readmission rates (16% vs. 12%, p=0.56), and mortality (1 death in each group, p=1), were also comparable. Both agents demonstrated similar safety profiles, with no significant differences in adverse events such as hypotension, urinary tract infections, or acute kidney injury (AKI). 


Conclusion: Dapagliflozin and empagliflozin appear equally effective and safe in managing ADHF, with comparable diuretic responses, hospital stay durations, and readmission rates. These findings support the use of SGLT2is in ADHF, regardless of the specific agent chosen. Future research should focus on prospective, multicenter studies to further validate these results and explore long-term outcomes. 

Objective: 
Investigate the incidence of culture-proven infection in pre-term and VLBW and low birth weight (LBW) neonates in the NICU at USACWH
 
Self-Assessment Question: 
What probiotic had the greatest incidence of positive cultures? A. Culturelle B. UP4 C. Ultimate Flora Baby


Background: 
Pre-term neonates have an immature gut barrier and alterations in the microbiota increase their risk for morbidity and mortality. Probiotics are used to colonize the gastrointestinal tract with beneficial microorganisms to prevent complications such as necrotizing enterocolitis (NEC) and colonization of Clostridium difficile. Currently, the American Gastroenterological Association (AGA) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) guidelines recommend probiotics in pre-term and low-birth weight neonates to prevent NEC in the hospitalized setting. A risk factor of probiotics in this patient population is the translocation of a probiotic species across their permeable barrier and out of the digestive tract.  The University of South Alabama Children’s and Women’s Hospital (USACWH) used probiotics liberally in the neonatal intensive care unit (NICU) until the fall of 2023. Probiotic use ceased after the U.S Food and Drug Administration (FDA) issued a healthcare warning on probiotic use in hospitalized pre-term or very low birth weight (VLBW) infants due to the potential risk of invasive and potentially fatal disease from live bacteria or yeast.   This study aims to investigate the incidence of culture-proven infection in pre-term and VLBW and low birth weight (LBW) neonates in the NICU at USACWH.
 
Methods: 
This is a single-site, retrospective review of neonates admitted to a level III NICU between 2017 and 2024.  The primary outcome was the incidence of positive cultures matching a probiotic species in preterm or VLBW and LBW infants. Pre-term neonates between 21 weeks to 38 weeks gestational age or LBW defined as < 2,500 grams, received > 72 hours of probiotics, and a positive culture matching the probiotic species were included. Patients were excluded if they were > 38 weeks gestational age, weighed > 2,500 grams, or received < 72 hours of probiotics. The key secondary data points include past medical history, type of probiotic, day of admission probiotics were initiated, duration of probiotic, type of culture, culture speciation, ICD-10 code for NEC, and cause of death.   Statistical tests used were means and standard deviations for descriptive statistics, Naranjo criteria, means and standard deviations.
 
Results:  
A total of 871 patients received probiotics. There was a total of 6 neonates with positive cultures matching the probiotic species. This correlates with an incidence rate of 0.69 new positive culture for every 100 patients.  All 6 neonates with positive cultures received Ultimate Flora Baby (UFB), containing Bifidobacterium spp (B. infantis, B. breve, B. longum, B. rhamnoses, B. acidophilus) and Lactobacillus spp (L. rhamnoses, L. acidophilus). Out of the 871 patients, 726 (83%) patients received UFB, 133 (15%) patients received UP4, and 12 (2%) patients received Culturelle.  A Naranjo score of 6 suggests the positive blood cultures were a probable adverse event from the probiotic. However, other factors might have contributed to the positive cultures. The results of the possible factors that may have contributed to the positive cultures are still pending.  
 
Conclusion: 
Among preterm, VLBW, and LBW infants receiving probiotics in the NICU at USACWH there was a low incidence rate of positive blood cultures.  Factors that could have contributed to the positive cultures is still in progress.  

Title:
Assessment of an AST:ALT Ratio for Predicting Clinical Recovery After Acetaminophen Poisoning


Authors:
Andrew Norton; Raymond Patterson; Jenna Jewett; Faisal S. Minhaj


Objective:
Evaluate the utility of an AST:ALT ratio for predicting clinical recovery after acetaminophen poisoning.


Self Assessment Question:
Based on the available evidence, should an AST:ALT ratio be used as a surrogate endpoint for determining when to discontinue NAC therapy? 


Background:
Previously, a transaminase ratio of 0.4 or less was proposed as a treatment cutoff for recovery of acetaminophen (APAP) toxicity. This study aims to evaluate the suggested transaminase ratio of <0.4 in a broader population by including all patients with transaminitis thought to be caused by acetaminophen toxicity. We also aim to evaluate different transaminase ratio thresholds to determine if a different ratio is applicable in a patient population that primarily consists of non-severe acetaminophen poisoning.


Methods:
This was a retrospective study conducted by reviewing the electronic medical record of patients who presented to WKRMC between January 1, 2022, and May 1, 2024, and received at least one dose of N-acetylcysteine (NAC) for the treatment of suspected or confirmed APAP toxicity. A total of 84 patients were included in the analysis, with a minimum requirement of 10 patients who received extended NAC therapy (i.e., beyond the standard 72-hour oral course or 21-hour intravenous course). 34 out of 84 patients had at least 1 AST or ALT value of 100 IU/L or more and completed their NAC treatment at WKRMC were included in the primary endpoint. This was determined to be exempt from IRB review at Wellstar Kennestone Regional Medical Center.


Results:
Of the 84 patients that were included in this study, only 34 (41%) patients achieved an AST:ALT ratio of 0.4 or less at the completion of NAC therapy. The most identified co-ingestions included EtOH, NSAIDS, opioids, and benzodiazepines. Extended NAC therapy was utilized in 17 (20%) patients.


Conclusion:
Evaluation of a transaminase treatment ratio of 0.4 or less did not result in a viable endpoint for NAC therapy discontinuation in our patient population for APAP toxicity. Additionally, there was no other ratio threshold endpoint deemed clinically significant for NAC therapy discontinuation.

Title: Clinical Outcomes for Recipients of Kidney Transplantation from Hepatitis C Virus-Infected Donors
Authors: Caitlyn Tyus, Sally Sikes, Caroline Gatzke, Victoria Burnette
Objective: To assess allograft survival status at one year post-transplant for recipients of Hepatitis C Virus (HCV) NAT-positive donor kidneys in comparison to those who received kidneys from NAT-negative donors
Self Assessment Question: Does receiving a kidney from an HCV NAT-positive donor affect allograft survival status at one year post-transplant compared to HCV NAT-negative donor kidney recipients?
Background: According to the Organ Procurement and Transplantation Network, over 86% of individuals currently awaiting organ transplantation are specifically in need of a kidney. Despite this high demand, a significant number of potentially life-saving organs have been discarded due to donor Hepatitis C virus (HCV) infection. Since the introduction of direct-acting antivirals (DAAs) in 2014, these treatments have demonstrated to be both safe and effective for managing HCV in patients with chronic kidney disease (CKD) and kidney transplant recipients. Nonetheless, kidneys from HCV-positive donors still faced a 48% increased risk of discard in 2019.
Methods: This study was a single-center retrospective chart review conducted at Ascension Saint Thomas Hospital West (ASTHW) to compare clinical outcomes of deceased-donor kidney transplants from HCV-infected donors versus donors without HCV. The study included patients who received a deceased-donor kidney transplant at ASTHW between November 11, 2020 - October 18, 2023. Patients were included when the following criteria was met: kidney transplant recipient, age ≥18 years at time of transplant. Exclusion criteria included patients with a history of transplant, documentation of  dual-organ transplant, pregnant individuals, and incarcerated patients. The primary outcome was the allograft survival status at one year post-transplant for recipients of NAT-positive donor kidneys in comparison to those who received kidneys from NAT-negative donors. Secondary outcomes included incidence of HCV following transplant, rate of HCV recurrence following DAA therapy, and the utilization of various HCV treatment regimens.
Results:  In total, 350 patients were screened, with 91 meeting inclusion criteria, and 84 available for follow-up at one year post-transplant (42 in the HCV Donor Positive (POS) group and 42 in the HCV Donor Negative (NEG) group). There was no significant difference in allograft survival status at one year post-transplant between groups (p=0.457). Secondary outcomes conveyed that 64% of patients who received HCV NAT(+)  kidneys actually contracted HCV following organ transplantation. The HCV treatment of choice was sofosbuvir-velpatasvir, with glecaprevir-pibrentasvir being utilized in two patients due to the drug interaction between sofosbuvir-velpatasvir and amiodarone. Clearance of HCV was achieved by 85% of patients following initial therapy, two patients (7.5%) reported  HCV breakthrough following clearance, one patient (3.7%) experienced treatment failure, and one patient expired during HCV treatment (unrelated to HCV or treatment). The HCV treatment failure was determined to be caused by medication noncompliance. One of the HCV breakthroughs following clearance patients was due to medication noncompliance, while the other was due to the drug interaction and administration timing between sofosbuvir-velpatasvir and magnesium oxide. The secondary treatment following breakthrough or failure was sofosbuvir-velpatasvir-voxilaprevir. 
Conclusion:  In this study, there was no significant difference in allograft survival between HCV-positive and HCV-negative donor kidney transplant recipients. Interestingly, 36% of patients who received HCV NAT-positive donor kidneys did not contract HCV or require DAA therapy following transplantation; this result was correlated with donor kidneys with HCV NAT-positive but HCV antibody negative results. Limitations of this study included small sample size and inability to represent other HCV treatment regimens. Utilizing HCV-positive donor

Title: EFFICACY OF BALANCED SOLUTIONS VERSUS NORMAL SALINE ON DIABETIC KETOACIDOSIS RESOLUTION
Authors: Benny Zhang, PharmD, Bibidh Subedi, PharmD, BCCCP, Otsanya Ochogbu, PharmD


Background: Diabetic keto-acidosis (DKA) is a serious life-threatening complication. The initial management involves fluid resuscitation with crystalloids to restore intravascular volume. Current guidelines recommend normal saline (NS), however emerging evidence suggest that balanced crystalloids, such as Lactated Ringer’s (LR), may be a more appropriate choice of fluid in the acute management of DKA given the risk of hyperchloremic non-anion gap metabolic acidosis and acute kidney injury with NS. The purpose of this study is to compare the efficacy of LR versus NS in the management of DKA.


Methods: This is a multi-site, retrospective, observational study at a 3,260-bed community teaching hospital system comparing LR to NS in patients admitted with DKA. Patients will be identified via the electronic medical record and included if age 18 or greater, admitted between August 1st, 2022 to August, 31st, 2024 with a confirmed diagnosis of DKA (using ICD-9/10 codes or according to the ADA guideline criteria, defined as: blood glucose >200 mg/dL or prior history of diabetes, β-Hydroxybutyrate concentration ≥3 mmol/L, and pH <7.3 and/or bicarbonate <18 mEq/L), that received continuous infusions of either LR or NS. Patients were excluded if they were transferred from an outside hospital and had end-stage renal disease. The primary outcome was time to DKA resolution (defined as: (1) blood glucose <200 mg/dL and two of the following (2) bicarbonate ≥ 18 mEq/L, venous pH ≥ 7.3, and a calculated anion gap ≤ 12 mEq/L). Secondary outcomes include incidence of hyperchloremic non-anion gap metabolic acidosis, incidence of hypokalemia, time to discontinuation of maintenance fluid, acute kidney injury, ICU length of stay, and hospital length of stay.


Results: A total of 1738 patients were screened for inclusion: 274 patients in the LR group and 1464 patients in the NS group. 152 patients were included in the study, with 76 patients in each group. The baseline median anion gap (33 mmol/L vs 23 mmol/L; p<0.001) and β-Hydroxybutyrate (8.6 mmol/L vs 4.8 mmol/L; p<0.001) was higher in the LR group compared to the NS group, respectively. Additionally, the baseline median pH (7.13 vs 7.24; p<0.001) and bicarbonate (9 mmol/L vs 15 mmol/L; p<0.001) was lower in the LR group compared to the NS group, respectively. There was no difference in comorbidities between groups and the most common cause for DKA was non-compliance (49%). More patients in the LR group were classified as severe DKA when compared to the NS group; 59% vs 24%, p<0.001. The total amount of intravenous fluid received was greater in the NS group compared to the LR group: 5842 mL vs 4575 mL, p=0.006. Lactated Ringer’s was associated with faster time to DKA resolution and time to anion gap closure when compared to NS; 20.5 hr vs 24.1 hr (p=0.022) and 16.4 hr vs 20.3 hr (p=0.004), respectively. There was no difference in the incidence of hyperchloremic non-anion gap metabolic acidosis, hypokalemia, time to discontinuation of maintenance fluid, acute kidney injury, and hospital length of stay. ICU length of stay was longer in the LR group (51 hours) compared to the NS group (38 hours), p=0.015.


Conclusion: The use of LR in patients with DKA was associated with a faster time to DKA resolution and anion gap closure compared with NS, with no difference in adverse events between both groups. The findings of this study suggest that balanced crystalloids may be a more appropriate choice of fluid therapy in the management of DKA, but larger prospective studies are warranted to validate the findings of this study.

Abstract Title: 
Evaluation of Hospital Admissions for Diabetic Ketoacidosis Following the Initiation of Empagliflozin in a Veteran Population
 
Authors: Connor Landers, Rose Weldon
 
Background/Purpose: 
Empagliflozin is a sodium-glucose co-transporter 2 inhibitor (SGLT2) that is commonly utilized in the treatment of type-2 diabetes, chronic kidney disease, and in the setting of heart failure to reduce hospitalizations and mortality. Diabetic Ketoacidosis (DKA) is a life-threatening emergency that can be a challenging diagnosis for many practitioners. The purpose of this project is to retrospectively evaluate the prevalence of hospitalizations at the Birmingham VA Healthcare System (BVAHCS) for DKA in veterans currently prescribed empagliflozin.
 
Methods:
This quality improvement project was a single center, retrospective observational chart review. Data obtained was collected from October 2023 to January 2025. Two separate groups of veterans were identified on initial data extraction. Group one consisted of veterans with an active empagliflozin prescription within 90 days prior to admission. Patients in this group were also included based on the day supply of their prescription plus an additional 30 days to account for potential mailing issues or non-adherence. Group two consisted of veterans not prescribed empagliflozin. From these two groups, all veterans were sorted by admission diagnosis, labs, or the need for an insulin drip during admission. Veterans were included within this study based on their diagnosis of DKA during admission, a calculated anion gap > 12, the presence of ketones on urinalysis, a detectable beta-hydroxybutyric acid, or the initiation of an insulin drip during admission. Veterans were excluded if they had type-1 diabetes or were followed by palliative/hospice care. The primary endpoint was the rate of DKA occurrence in patients prescribed empagliflozin compared to veterans not on the medication. The secondary endpoint was the average duration of hospitalization. Other observations included the average blood glucose level noted on admission, whether the patient received treatment, the percent of empagliflozin discontinuations at discharge, the appropriate reporting to the VA Adverse Drug Event Reporting System (VADERS), and mortality rates.
 
Results:
From the initial data extrapolation, a total of 7,560 admissions were identified for the prespecified groups. The VA Adverse Drug Event Report for all adverse drug events (ADE) attributed to empagliflozin during the specified period was extracted for comparison to help ensure reported incidences of DKA were not missed.  A total of 151 ADE reports were identified of which 18 total incidences of DKA (11.9% of total ADE reports for empagliflozin) were extracted and further analyzed. Overall, 59 total patient charts were included into this project’s final analysis of data. On average, patients on empagliflozin and admitted for DKA were found to be 67 years of age and the majority were male (84.6%). The overall incidence of DKA between groups was determined to be 2.38% (27 of 1,134 admissions) in patients on empagliflozin and 0.56% (36 of 6,426 admissions) in patients who were not prescribed the medication. Our secondary endpoint, the duration of hospitalization, was similar between both groups (7.6 days vs 7.9 days). Other observations included a lower average blood glucose on admission for patients on empagliflozin (339 mg/dL vs 551 mg/dL), 96% of patients on empagliflozin were treated, empagliflozin was discontinued in 89% of veterans at discharge, and only 11% of patients experienced mortality. One substantial finding of this project noted only 59% of DKA admissions for patients on empagliflozin were appropriately reported to VADERS.

Conclusion:
A higher prevalence of DKA admissions was observed in the sodium-glucose cotransporter-2 inhibitor (SGLT2) group as compared to veterans not taking the medication. This project identified high rates of patients receiving treatment in some capacity; however, adverse drug event reporting was found to be substantially low. Based on the findings of this project further education to providers, pharmacists, and patients can help improve identification and reporting of DKA within the BVAHCS.

Title: Evaluating The Incidence of Adverse Effects Associated with High-Dose Intrapartum Vancomycin Administration for Group B Strep Prophylaxis


Authors: Jesse Klus, Kendall Heetdirks, Tanya Makhlouf


Objective: Evaluate the incidence of acute kidney injury and other pertinent adverse reactions in pregnant patients receiving high-dose vancomycin for intrapartum Group B Strep prophylaxis 


Self Assessment Question: MJ is a 29 YOF G1P0 at 39w5d who presents in active labor. She has had an uncomplicated pregnancy course thus far. She was found to be GBS positive and does have a high-risk allergy to penicillin. Clindamycin susceptibilities are unknown Her Scr is 0.89 and she weighs 70 kg. Which of the following would be the best regimen for GBS prophylaxis? 
A.Vancomycin 1000 mg IV Q12h
B.Clindamycin 900 mg IV Q8h
C.Cefazolin 2000 mg IV Q8h
D.Vancomycin 20 mg/kg IV Q8h


Background/Purpose: Prior to the implementation of intrapartum Group B Strep (GBS) prophylaxis, GBS was the most common cause of neonatal sepsis. Approximately 50% of women who are colonized with GBS will transmit the bacteria to their newborn either during the intrapartum period or after rupture of membranes. Without the use of prophylactic antibiotics in the intrapartum period, about 1-2% of newborns exposed to GBS develop early onset infections. The American College of Obstetricians and Gynecologists (ACOG) recommends administering GBS prophylaxis to women who have either known or unknown GBS colonization to decrease the rate of transmission to the neonate. Penicillin G is the preferred agent for GBS prophylaxis; however, cefazolin can be utilized in patients who have a low-risk penicillin allergy and vancomycin is preferred in patients who have a high-risk penicillin allergy and either known or unknown resistance to clindamycin. In June 2019, the recommended vancomycin dose was increased from 1000 mg IV every 12 hours to 20 mg/kg/dose (max 2000 mg) IV every 8 hours based on studies evaluating maternal and neonatal vancomycin levels. The purpose of this study was to evaluate the incidence of adverse effects associated with high-dose vancomycin for GBS prophylaxis during labor. 
 
Methodology: This was a multi-center, prospective, IRB approved, cohort study conducted at the Moses Cone Women’s and Children’s Center and Alamance Regional Medical Center in Greensboro, NC. On October 4, 2023, both centers adopted the vancomycin 20 mg/kg/dose every 8 hours dosing regimen for GBS prophylaxis in the intrapartum period. Patients were included in if their gestational age was at least 23 weeks and received at least one dose of vancomycin for GBS prophylaxis from October 1, 2022, to November 1, 2024. Patients were excluded if they received antibiotics for another indication, received an antibiotic for GBS prophylaxis other than vancomycin, had known intrauterine fetal demise, or were dialysis dependent. The primary objective was the incidence of acute kidney injury (AKI) following vancomycin dosing, as defined by an increase in serum creatinine of at least 0.3 mg/dL within 48 hours. Secondary objectives further evaluated the safety of high-dose vancomycin. Results were evaluated utilizing Fisher’s Exact and two sample T-tests.  
 
Results: A total of 93 patients were included in the analysis. There were 2 incidences of AKI in the post-group compared to none in the pre-group (p = 0.19). There was no statistically significant difference seen in the rates of GBS infection of the newborn and vancomycin flushing reactions between groups. More doses of vancomycin were given in the post-group (2.0 vs 1.7, p = 0.14) and the dose of vancomycin was higher in the post-group (1625 mg vs 1000 mg, p < 0.001). There were no trough levels obtained in the pre-group and five trough levels obtained in the post-group. The majority of trough levels drawn in the post-group were supratherapeutic.
 
Conclusions: High-dose vancomycin was not associated with a significant increase in AKI.   The difference seen in trough levels obtained between groups can be attributed to both increased dosing frequency in the high-dose group and overall short labor durations, making obtaining trough levels less feasible. While most of the trough levels obtained in the high-dose group were supratherapeutic, there was no indication that this resulted in increased adverse events. Additionally, the new dosing regimen provided adequate protection against GBS in newborns, as indicated by low infection rates. This evaluation demonstrates that high-dose vancomycin is a safe regimen for GBS prophylaxis in the intrapartum period. Larger evaluations are necessary to confirm the findings of this study.  

Title:  Optimal Enoxaparin Dosing in Children with Congenital Heart Disease Less than 1 Year of Age 


Authors: Katelyn Price, Hania Zaki, Haseena Hussain, Jennifer Sterner Allison, Helen Giannopoulos, Gary Woods, Josh Branstetter 


Objective: Evaluate enoxaparin dosing regimens in children with congenital heart disease in patients less than 1 year of age. 


Self Assessment Question: 
Which of the following enoxaparin dosing strategies would be best to use to acheive initial therapeutic levels quicker based on the results of this study?
A. 0.75 mg/kg q12h
B. 1 mg/kg q12h 
C. 1.5 mg/kg q12h
D. 1 mg/kg q24h 


Background: Venous thromboembolism (VTE) prevalence amongst pediatric patients with congenital heart disease has increased over the years. Enoxaparin’s pharmacokinetic properties and less intensive monitoring parameters make it a desirable treatment option. Currently, reported enoxaparin dosing strategies and their correlation to therapeutic anti-Xa levels are variable for infants aged 2 to 12 months.  


Methods: This was a single center, retrospective, quasi-experimental study conducted between January 2008 and June 2023 in patients receiving therapeutic enoxaparin. Patients were divided into pre (January 2008 to December 2014) and post (June 2020 to June 2023) intervention groups, with the pre-intervention group receiving an enoxaparin dosing regimen of 1 mg/kg every 12 hours (standard dose) and post-intervention group receiving an enoxaparin dosing regimen of 1.5 mg/kg every 12 hours (high dose). Patients were included if they were between the ages of 2 to 12 months of age, admitted to the heart center, and had at least one heparin assay drawn 4-6 hours after a dose. Patients were excluded if they had thrombocytopenia defined as platelets at baseline less than 100,000 plts/µL, poor renal function defined as a creatinine clearance less than 30 ml/min, or an anti-xa goal other than 0.5 - 1 unit/ml. The primary objective was to evaluate the percent of patients who achieved initial target anti-xa levels. Secondary objectives included time to target anti-Xa level, number of dose changes needed to obtain goal anti-xa levels, and bleeding.


Results: A total of 85 patients were included in this study, 33 in the standard dose group and 52 in the high dose group. The median age was 3.73 months (IQR 3.01 to 6.53) in the standard group and 4.18 months (IQR 3.08 to 5.76) in the high dose group. There were similar demographics between both groups with the exception of more Black or African American (29 (56%) vs 8 (24%); p = 0.003) patients in the high dose group. More patients in the high dose group achieved initial therapeutic levels of enoxaparin (36 (69%) vs 5 (15%); p < 0.001).  The time between initial dose of enoxaparin and first therapeutic anti-Xa level was longer in the standard dose group compared to the high dose group, respectively (87 hrs (IQR 41 to 112) vs 24 hrs (IQR 16 to 40; p< 0.001)).  There was no difference in the incidence of minor bleeding (6 (18%) vs 5 (6%); p = 0.084) or major bleeding (1 (3%) vs 7 (13%); p = 0.14) between the standard and high dose groups, respectively. 


Conclusion: High dose enoxaparin in infants with congenital heart disease resulted in a higher percentage of initial anti-Xa target attainment and a decreased time to target anti-Xa level. There was no difference in minor or major bleeding between the standard and high dose strategies. Based on our findings, it is safe and effective to dose enoxaparin higher in infants with congenital heart disease.  

Title: Incidence of oral candidiasis post kidney transplant in patients with or without oral nystatin prophylaxis 
Authors: Hannah Green, Alexandra Pyatt, Lindsay Reulbach, Rachel Gustafson, Carlos Zayas, and Alex Ewing 
 
Background: Renal transplant recipients (RTRs) are at increased risk for fungal infections, particularly oral candidiasis (OC), due to maintenance immunosuppression. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend 1-3 months of fungal prophylaxis with oral fluconazole, clotrimazole troches, or nystatin suspension. However, the American Society of Transplantation does not endorse routine Candida prophylaxis. The necessity of fungal prophylaxis is questioned given the low incidence of OC, ease of treatment, and potential non-adherence to nystatin. The purpose of this study aimed to evaluate the incidence of OC within 60 days post-transplant in patients with and without 30-day nystatin prophylaxis. 
 
Methods: A single-center, retrospective study was conducted at Prisma Health Greenville Memorial Hospital in patients 18 years or older who underwent a single renal transplant between July 2023 and January 2024 (with prophylaxis) and February 2024 to August 2024 (without prophylaxis). Exclusion criteria included concomitant use of systemic antifungals, antifungal use within 30 days prior to transplant, a history of OC, or a history of prior transplant or dual organ transplant. The primary outcome was the incidence of OC within the first 60 days post-transplant. Secondary outcomes included the occurrence of esophageal candidiasis (EC), systemic fungal infections, inpatient readmissions for OC, and the duration of OC treatment. 
  
Results: A total of 173 transplant patients were screened and 132 were included in the final analysis with 64 in the without prophylaxis group and 68 in the prophylaxis group. At baseline, more patients in the prophylaxis group were on tacrolimus and mycophenolate maintenance regimens, had steroids withdrawn, and used fewer additional steroids. The incidence of OC was similar between groups, with two cases in each (2.9% vs. 3.1%, p=1.000), all of which were treatable. None of the secondary outcomes were statistically significant, though two cases of EC occurred in the prophylaxis group. Only one patient in the prophylaxis group required readmission for OC, and both OC cases in the without prophylaxis group involved additional steroid use. 
 
Conclusions: The findings of this study demonstrate that the incidence of OC was low and, when it occurs, was easily treatable. There was no statistically or clinically significant difference in OC incidence between the prophylaxis and without prophylaxis groups, despite the latter group being more immunosuppressed. Given the comparable rates of OC between the two groups, nystatin prophylaxis does not appear to be warranted in this transplant population. Therefore, no modifications to current clinical practices are recommended. 

Title: Evaluating the Safety and Efficacy of an Automatic 24-hour Stop Date for Antibiotics in the Treatment of Early-Onset Sepsis in the Neonatal Intensive Care Unit


Authors: Tyler Tolbert, Corinne Murphy, McKenzie Hodges, Darryl Wanton Jr.


Background: Early-Onset Sepsis (EOS) remains a significant concern in the neonatal intensive care unit (NICU), necessitating the use of empiric antibiotic therapies. However, prolonged antibiotic exposure is associated with adverse neonatal outcomes including disruption of normal flora, increased incidence of antibiotic resistance, and increased risk for necrotizing enterocolitis. Previous practice included 72 hours of empiric antibiotics for EOS which caused an increase in duration of therapy even though typical pathogens can be identified within 24 hours. Our institution previously had an automatic stop date of 36 hours for EOS antibiotics, but we recently transitioned to an automatic stop date of 24 hours for EOS antibiotics in order to reduce unnecessary drug exposure. This study evaluated the safety and efficacy of implementing a 24-hour automatic stop date for empiric antibiotics in neonates suspected of EOS compared to the previous 36-hour protocol. 

Methods: This study was a single-center, retrospective, pre/post-implementation chart review. Neonates receiving antibiotics for EOS were categorized into two groups based on treatment periods: pre-implementation (36-hour protocol) and post-implementation (24-hour protocol). The primary outcome was treatment failure, defined as the resumption of antibiotics within 72 hours of discontinuation. Secondary outcomes included the incidence of necrotizing enterocolitis, mortality, and length of hospital stay. Data on neonatal demographics, antibiotic duration, and clinical outcomes were collected and analyzed. Comparative analyses using chi-squared and t-tests were used to assess statistical significance between the two groups.
 
Results: For our primary outcome of treatment failure there was no statistical difference in the incidence of treatment failure between a 24 hour automatic stop date and a 36 hour automatic stop date for empiric antibiotics. For our secondary outcomes, late onset sepsis was not observed in either study group during the study period. There was also no statistical difference between the groups when analyzing the incidence of death which occurred in 9% of patients on 24-hour protocol and 10.5% of patients on the 36-hour protocol, or the incidence of necrotizing enterocolitis which occurred in 3% and 5.3% of patients respectively. The average length of stay was also not statistically significant between the groups, but there was a longer average length of stay during the 36 hour protocol time frame.

Conclusion: This study assessed the impact of implementing a 24-hour empiric antibiotic stop date for early-onset sepsis in the Neonatal Intensive Care Unit. The results showed that reducing the duration of empiric antibiotics from 36 to 24 hours was not associated with an increased rate of treatment failure. This is a significant finding because it suggests that a shorter antibiotic duration may be just as effective in ruling out early-onset sepsis while also reducing unnecessary antibiotic exposure.
 
Contact: tyler.tolbert@piedmont.org

Title: Impact of Concomitant Antibiotic Use on Treatment Outcomes in Patients with Clostridioides difficile Infection Receiving Fidaxomicin.


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


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


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


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

Title: Time to Cytomegalovirus Viremia After Valganciclovir Discontinuation in Intermediate and High-Risk Kidney Transplant Recipients


Authors: Morgan Pickard, Kwame Asare, Caren Azurin, Taylor Nickens


Objective: Duration from valganciclovir discontinuation to cytomegalovirus viremia in intermediate and high-risk kidney transplant recipients


Self Assessment Question: Does valganciclovir discontinuation impact time to CMV viremia in intermediate and high-risk kidney transplant recipients? 


Background: Cytomegalovirus (CMV) infection is the most common opportunistic infection following solid organ transplantation, particularly affecting transplant recipients at intermediate (INT) (recipient positive) and high-risk (donor positive, recipient negative) for CMV reactivation. Reactivation can lead to serious complications such as tissue invasion and increased risk of rejection, opportunistic infection, and mortality. Valganciclovir (VGCV) is guideline approved for prophylaxis in these two groups, but its use can be limited by adverse effects such as leukopenia, which occurs in about 50% of patients. Despite the widespread use of VGCV, there is limited research examining whether the duration from VGCV discontinuation to CMV viremia varies between INT and high-risk kidney transplant recipients. This study aimed to evaluate if there is a difference in the mean duration from VGCV discontinuation to CMV viremia between these two groups.


Methods: This single-center retrospective chart review utilized electronic medical records and organ transplant tracking record (OTTR) software at Ascension Saint Thomas Hospital West (ASTHW), with data collected from March 2018 to April 2024. Kidney transplant recipients were identified via OTTR, and data from INT and high-risk groups were analyzed. Patients were categorized into INT and high-risk groups and screened for eligibility based on inclusion/exclusion criteria. Eligible participants were adults (≥ 18 years) who received a kidney transplant, were at INT or high-risk for CMV, discontinued VGCV, and developed CMV viremia. Exclusion criteria included dual organ transplants, pregnancy, incarceration, and restarting VGCV after rejection. The primary outcome assessed the difference in the mean duration from VGCV discontinuation to CMV viremia between the two groups. Secondary outcomes included rejection rates, readmission, resistant CMV, and bacterial, viral, or fungal infections after CMV viremia.
Results: A total of 202 patients were included, with 147 in the INT-risk and 55 in the high-risk groups. CMV viremia developed in 1 (6%) INT and 6 (43%) high-risk patients following VGCV discontinuation during the prophylactic period (p = 0.018). There were no significant differences in the duration of VGCV discontinuation to CMV viremia (42 vs. 43 days, p = 0.999). Additionally, there were no significant differences between the groups in rejection rates (0% vs. 0%, p = 0.999), readmission rates (100% vs. 50%, p = 0.999), infection rates (0% vs. 0%, p = 0.999), and resistant CMV rates (0% vs. 17%, p = 0.999). However, CMV developed in 37 (25%) INT and 12 (24%) high-risk individuals within 3 months following prophylaxis. The time from VGCV discontinuation to CMV viremia during this time was significant between the groups (56 vs. 36 days, p = 0.021). The average interval between CMV tests was also significant (21 vs. 12 days, p  < 0.0001).


Results: A total of 202 patients were included, with 147 in the INT-risk and 55 in the high-risk groups. CMV viremia developed in 1 (6%) INT and 6 (43%) high-risk patients following VGCV discontinuation during the prophylactic period (p = 0.018). There were no significant differences in the duration of VGCV discontinuation to CMV viremia (42 vs. 43 days, p = 0.999). Additionally, there were no significant differences between the groups in rejection rates (0% vs. 0%, p = 0.999), readmission rates (100% vs. 50%, p = 0.999), infection rates (0% vs. 0%, p = 0.999), and resistant CMV rates (0% vs. 17%, p = 0.999). However, CMV developed in 37 (25%) INT and 12 (24%) high-risk individuals within 3 months following prophylaxis. The time from VGCV discontinuation to CMV viremia during this time was significant between the groups (56 vs. 36 days, p = 0.021). The average interval between CMV tests was also significant (21 vs. 12 days, p  < 0.0001).


Conclusion: No significant differences were found in the time from VGCV discontinuation to CMV viremia, or in rejection, readmission, infection, or resistant CMV rates during the prophylactic period. However, our study found that stopping prophylactic VGCV increases CMV risk, especially in the high-risk group. CMV was common in the first three months post-prophylaxis. We recommend CMV monitoring every 14 days during this period.

Title: Dose-Dependent QTc Prolongation of Methadone in Pediatric Patients


Authors: Kaitlyn Currie, Justin K. Chen, Janae Townsend, Jillian Mantione


Objective: Determine thedose relationshipfor methadone and QTc prolongation in the pediatric population.


Background: Methadone is a synthetic opioid commonly used to wean patients off continuous opioid infusions to prevent withdrawal. Methadone is associated with prolongation of the QTc intervalon electrocardiogram (EKG). In pediatric patients, the dose-dependent relationship of methadone to QTc prolongation has not been established. The primary aim of this study was to investigate the risk of QTc prolongation in pediatric patients maintained on methadone at Children’s Healthcare of Atlanta. 


Methods: A retrospective chart review of patients less than 18 years old initiated on methadone between January 1, 2023 and April 30, 2024, in the intensive care setting. Patients were excluded if they received methadone for <24 hours, did not have EKG results while on methadone, had a history of long QT syndrome, or if they were on methadone for the following indications: chronic pain, palliative care, and/or addiction.

Results: A total of 79 patients met criteria for inclusion, comprised of 266 EKGs. The median age was 0.91 years (IQR 0.36-5.49) with 40 (50.9%) of patients being male. The median baseline QTc was 424 ms (IQR 408-441) for those who had an EKG prior to methadone initiation. There was no correlation between methadone weight-based dose and length of QTc (r=0.07, p=0.23). An analysis comparing low (<0.25 mg/kg/day), moderate (0.25-0.5 mg/kg/day), and high (>0.5 mg/kg/day) dosing of methadone did not show a difference in QTc among the three groups (p=0.71). A secondary analysis comparing patients with a baseline QTc and their QTc on methadone showed no difference (424 ms versus 430 ms, p=0.24).  

Conclusion: This retrospective analysis could not determine a relationship between weight-based methadone dosing and QTc. Patients did not experience a statistically significant difference between their baseline QTc and their QTc on methadone. 

Title: Implementing a Pharmacy Clinical Decision Support Council for a 54Hospital health-system.

Authors: Sabrina Desmond, Pharm.D.; Fei Wang, Pharm.D.; Craig MacDonald, Pharm.D.

Objective: To describe the creation and maintence of a clinical decision support oversight group to manage alerts within a multi-state health system.

Self Assessment Question: True or False: The only purpose of a clinical decision support council is to eliminate as many alerts as possible to reduce alert fatigue.

Background: Pharmacy-driven clinical decision support (CDS) is a critical element for optimizing medication safety and therapeutic outcomes in inpatient hospital systems. Pharmacy teams often manage an extensive array of drug-related alerts that can range from formulary and dosing recommendations to drug interactions and therapeutic duplications. Without focused oversight, these alerts can become overwhelming and lead to alert fatigue which could compromise the quality of patient care. A pharmacy-specific CDS Council can address these challenges by standardizing alert strategies, prioritizing clinically relevant notifications, and driving evidence-based enhancements to medication-related workflows.

Methods: Constructing an advisory group to oversee drug-related alerts required several steps:

• Establishing a workflow for alert review submissions
• Creating specialized workgroups that could provide insight for alert reviews
• Construct a voting structure that allows for diverse assessment and input

Items are entered into the CDS review process by inputting a request into a ticket management platform. After submission, items are reviewed by a workgroup comprised of electronic health record (EHR) analysts and pharmacy informatics experts to evaluate the request and propose solutions for consideration. Following that initial review, solutions are discussed and voted on independently by a medication safety workgroup and a clinical workgroup. Each of these workgroups have at least one representative from each of the eight regions within the hospital system. Finally, solutions and voting results are presented to a final council that includes leaders in clinical, medication safety, EHR, and informatics specialties. All results are discussed, and final actions are determined.

To evaluate the interventions made by this CDS council, requests have been categorized into 4 groups: alert deactivation, alert activation, creation of a custom alert, and no action taken. A secondary analysis was performed to better understand the reasons for taking no action. Therefore, the group "no action taken" was further subcategorized into one of the following: alert is appropriate, alert is not indicated, functionality not available, or exists in current state.

Results: A total of 59 items were tracked from August 1st, 2024 - March 31, 2025.The number of items reviewed were categorized into the 4 groups as follows:

• Alert deactivation: 4 items 
• Alert activation: 11 items
• Creation of custom alert: 12 items
• No action taken: 32 items

Since there were 32 items that were categorized as "no action taken," these items were further subcategorized as follows:

• Alert is appropriate: 18items 
• Alert is not indicated: 5 items
• Functionality not available: 5 items
• Exists in current state: 4 items

Conclusion: A structured workflow is needed in order to perform a systematic review and comprehensive assessment for CDS enhancements within a health system. By gathering insight from diverse specialties and system-wide representatives, balanced adjustments can be made to alert settings. These adjustments potentially lead to management of alert fatigue and other limitations experienced with CDS tools. Further investigation is needed to assess the overall impact that is made when adjusting alert settings. Additionally, further optimization and expansion of the CDS Council process can allow for proactive investigation of potential alert adjustments as well as an assessment of other CDS components beyond alert settings.

Title: Comparative Outcomes of Post-Transplant Cyclophosphamide (PTCy) vs Non-PTCy-Based GVHD Prophylaxis Regimens in Allogeneic Hematopoietic Stem Cell Transplantation


Authors: Gyunash Akibova, Kristen Kilby, Henry Kent Holland, Justin LaPorte, Eva Karam 
 
Objective: This study aims to evaluate the long-term outcomes of PTCy-based GVHD prophylaxis in alloHSCT recipients over a 10-year period at Northside Hospital. The primary objective is to assess chronic GVHD-free relapse-free survival (CGFRFS) in patients receiving PTCy compared to those who did not. Secondary objectives include evaluating overall survival (OS), relapse-free survival (RFS), NRM, and the incidence of acute and chronic GVHD.
 
Background: Graft-versus-host disease (GVHD) is a significant complication following allogeneic hematopoietic stem cell transplantation (alloHSCT), particularly in patients with human leukocyte antigen (HLA)-mismatched or haploidentical donors. Traditional GVHD prophylaxis regimens, such as a calcineurin inhibitor (CI) and methotrexate (MTX), have been effective but are still associated with risks of acute and chronic GVHD, as well as non-relapse mortality (NRM). Post-transplant cyclophosphamide (PTCy) alone or in combination with a CI with or without mycophenolate has emerged as a promising approach for GVHD prophylaxis, showing favorable results in reducing GVHD incidence in alloHSCT recipients. A recent retrospective study at The Blood and Marrow Transplant Program at Northside Hospital suggested the benefits of PTCy beyond haploidentical transplants, prompting further investigation into its long-term outcomes.
 
Methods: This single-center, retrospective chart review will include patients who underwent alloHSCT at Northside Hospital between January 1, 2013, and December 31, 2023. Recipient health records will be identified using a proprietary database to identify patients who received an alloHSCT during the study period. Data will be extracted from electronic health records (Cerner Powerchart®, OncoEMR®) and hospital databases. Patients will be excluded if they are receiving a second alloHSCT. Key data points include patient demographics, HLA disparity, use of PTCy, GVHD incidence, time to GVHD onset, disease relapse, and survival outcomes. 
 
Results: In Progress
 
Conclusion: In Progress

TITLE: Utility of Clonidine Conversion to Prevent Dexmedetomidine Withdrawal Syndrome in Pediatric Patients
 
AUTHORS: Emily Hardy, Andrea Gerwin, Renee Hughes, Paige Klingborg 
 
BACKGROUND: In 2022, the Society of Critical Care Medicine (SCCM) issued a guideline recommending alpha-2 receptor agonists as the preferred class for sedation in critically ill pediatric patients. Amidst emerging concern regarding potential dexmedetomidine withdrawal in this population, recent evidence has supported the use of clonidine, another alpha-2 agonist, as a bridging agent to mitigate or prevent withdrawal. While some institutions may have implemented the use of clonidine in dexmedetomidine weaning, there is no consensus or validated protocol. This study aimed to examine the relationship between cumulative dexmedetomidine exposure and clonidine requirements and will expand upon a previous analysis at the study site that focused on a period prior to the SCCM guideline update.  

METHODS: This IRB-approved, single center, retrospective observational study focused on patients admitted to the PICU from January 2018 to May 2024. Inclusion criteria included receipt of a continuous dexmedetomidine infusion > 24 hours and enteral clonidine for treatment or prevention of dexmedetomidine withdrawal. Patients were excluded if they used clonidine prior to admission or if clonidine was initiated for an alternate indication. Included patients were divided into two groups – a non-escalation and an escalation group – based on whether the patient received an increase in their clonidine dose (at provider discretion). The primary outcome assessed the relationship between cumulative dexmedetomidine exposure and maximum required clonidine dose. Secondary outcomes included dexmedetomidine withdrawal assessment, rate of clonidine failure following initial clonidine dose, hospital and ICU length of stay, ventilator days, central line days, and incidence of tracheostomy placement.
 
RESULTS: Compared to the non-escalation group, the escalation group had a statistically significant increase in duration of dexmedetomidine (346.4 vs 284.3, p-value=0.0114) and increased cumulative dexmedetomidine dose (341.2 vs 230.8, p-value=0.0128). The difference in initial clonidine dose was not significant (5.7 vs 4.9, p-value=0.7928). The escalation group had a statistically significant increase in hospital LOS (36 vs 27.5, p-value=0.0355) and ICU LOS (27 vs 20.5, p-value=0.0426). There was no statistically significant difference in ventilator days, CVL days, or incidence of tracheostomy.  
 
CONCLUSION: Higher cumulative dexmedetomidine exposure is associated with higher clonidine dose requirements. Both hospital and ICU LOS were significantly decreased in patients who did not require an increase in their clonidine dose. Utilizing cumulative dexmedetomidine exposure to determine initial clonidine dose may be beneficial.

Title: Transitioning RFID Medication Tray Solutions: A Nine-Hospital Network Implementation
Authors: Nina Desai, PharmD.; Hiren Shah, PharmD., BCPS; Craig MacDonald, PharmD.
Objective: To address the conversion between RFID systems and the challenges that arise during this process.
Self Assessment Question: True or False. Vendors will always be able to transfer currently tagged products to a new system during a vendor conversion. 
Background:
RFID (radio-frequency identification) in pharmacy enhances the accuracy and efficiency of medication management. By tagging medications with RFID, pharmacies can automate the tracking process and reduce human error. AdventHealth utilizes RFID technology for code trays and anesthesia station trays. Trays and medications are equipped with RFID tags containing unique identifiers for precise tracking and inventory control. The goal of the system is to monitor tray and medication inventory and notify staff when items are nearing expiration or trays need restocking.
AdventHealth is in the process of transitioning vendors for RFID tray solutions. The key benefit of System B is the ability to purchase pre-tagged items directly from AdventHealth’s established wholesaler.
During a brand-new RFID go live a drug library would be built and the items required in the pharmacy would be tagged and entered into the system. With a conversion the existing information and tagged products would ideally be transferable to the new system, removing potential work and redundant inventory. While most published information focuses on implementing new RFID system, this presentation addresses the conversion between RFID systems and the challenges that arise during this process.
Methods: 
AdventHealth’s Central Florida Division is transitioning from System A to System B in a structured three-phase approach. Each phase includes three hospitals and phase three includes sites using mobile solutions for anesthesia-station trays, including the 1,366-bed flagship hospital. The conversion is led by the pharmacy informatics team, vendor representatives and local pharmacy leadership.
System A was not able to transfer existing drug registry information into System B, requiring a conversion process for existing tagged inventory. The preparation of tagged items for the conversion involved commissioning medications previously tagged in System A, purchasing pre-tagged items from the wholesaler, and newly tagging items by the pharmacy.
An action plan was developed for the six weeks preceding the go-live. The first two weeks were spent gathering and preparing tray, NDC, user, and site data. The next week was dedicated to training users, with each site completing buyer, superuser, and general staff training. The following three weeks focused on commissioning to ensure tagged medication was available during go-live. Additionally, sites were encouraged to purchase additional inventory pre-tagged through the wholesaler associated with System B. The existing tagged inventory was separated by lot and commissioned, with daily tracking of commissioned items.
These commissioning weeks provided enough items to reach the project milestones (three-tiered progression):

1. Completed at least one of each tray template.
2. Completed at least three of each tray template.
3. Completed high-priority trays.

Results:
Phase one was completed in December 2024, and phase two will finish by mid-March 2025. The team initially faced a steep learning curve, including commissioning bottlenecks. During some commissioning steps, we are limited to a single System B kiosk, which caused significant bottlenecks. For reference, a smaller site with nearly 200 beds has an inventory of nearly 3,000 tagged items in System A that needed to be commissioned into system B.
The action plan was adjusted after each go-live, leading to significant improvements in preparation and execution. As the flagship hospital transitions to a mobile solution in phase three, the plan will continue to evolve.
Conclusion: In progress