2026 Eastern States Conference

Authors
Jae Sohn, PharmD 
Daryn Norwood, PharmD, BCPS 
Eun Jin Park, PharmD, BCPS, BCIDP 
Kelly Hu, PharmD, BCPS 
Nehal Ahmed, PharmD, BCPS 
 
Learning Objective 
To evaluate ceftriaxone and azithromycin duration of therapy for non-severe community-acquired pneumonia and assess the impact of pharmacist education on treatment duration. 
 
Background  
To evaluate the impact of pharmacist-led education on the duration of ceftriaxone and azithromycin therapy for non-severe community-acquired pneumonia. 
 
Methods
This single-center retrospective before-and-after study will include adults who received ceftriaxone and azithromycin for provider-diagnosed community-acquired pneumonia diagnosed at admission or within 48 hours of hospitalization. Patients will be excluded if clinical stability is not achieved within 72 hours, if methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, or Legionella pneumonia is suspected or confirmed, if structural lung disease or immunocompromising conditions are present, or if alternative antibiotics are required. The primary outcome will be the appropriateness of ceftriaxone and azithromycin therapy duration. Secondary outcomes will include total antibiotic duration, combined inpatient and outpatient ceftriaxone and azithromycin duration, 30-day readmission, and Clostridioides difficile infection within 30 days. 
 
Result:
Among 100 patients included (50 pre-intervention, 50 post-intervention), overall appropriateness of ceftriaxone and azithromycin duration increased from 18% to 44% (p=0.0089). Azithromycin appropriateness improved from 38% to 66% (p=0.0089), while ceftriaxone appropriateness increased from 42% to 58% (p=0.161). Mean total antibiotic duration decreased from 6.4 to 5.7 days. Mean ceftriaxone duration increased from 3.3 to 3.9 days, while mean azithromycin duration decreased from 3.1 to 3.0 days. Thirty-day readmission rates were unchanged between groups, and no 30-day C. difficile infections occurred.
 
Conclusion:
Pharmacist education was associated with improved guideline-concordant antibiotic duration for adults with community-acquired pneumonia, particularly for azithromycin. The greatest improvement was observed among patients with length of stay ≥48 hours, suggesting inpatient stewardship efforts may be most effective when there is sufficient time to intervene. Patients with shorter hospitalizations may benefit from discharge-focused interventions to optimize total antibiotic duration.

Self-Assessment Question:
For clinically stable patients with non-severe community-acquired pneumonia, what is the recommended maximum duration of therapy?
 A. Beta-lactam 5 days and azithromycin 3 days
 B. Beta-lactam 7 days and azithromycin 5 days
 C. Beta-lactam 10 days and azithromycin 5 days
 D. Continue both antibiotics until discharge

Authors: Jovina Fager, PharmD; Alex Matika, PharmD, BCIDP; Lauren Allen, PharmD, BCIDP; Julia Bold, PharmD; Esrat Jahan, PharmD; Justin Miller, PharmD

Learning objective: Evaluate the impact of preoperative antibiotic timing on odds of surgical site infection (SSI).

Background: The ideal timing of preoperative antibiotic administration in relation to incision time remains unclear. This study aims to evaluate the optimal timing of preoperative antibiotic administration to mitigate the odds of SSIs.

Methods: This study was a retrospective, case-control trial evaluating 993 adult patients admitted to St. Luke’s University Health Network for a surgical procedure from January 2022 to December 2024. Patients were included at a 1:4 case-to-control, with cases defined as patients who developed a SSI, and controls defined as patients without subsequent SSI. Patients were excluded if they did not receive preoperative antibiotics, received preoperative antibiotics > 120 minutes prior to incision, underwent more than one procedure during index hospitalization, or had a preexisting infection at time and anatomical site of index procedure. The primary outcome was SSI odds by preoperative antibiotic administration time. Secondary outcomes included admission, hospital length of stay, and readmission for SSI management; and mortality at 30 and 90 days post-operation. SSIs were categorized using National Healthcare Safety Network definitions. The primary outcome was assessed using logistic regression.

Results: Cefazolin was the most frequent preoperative antibiotic administered (863 of 993 cases). This study demonstrated that cefazolin administration beyond 45 minutes prior to incision was associated with increased odds of SSI compared with administration at 15-45 minutes (OR 3.30, 95% CI 1.30-8.42; p = 0.012). In the subgroup analysis, clindamycin was associated with increased odds of SSI compared with cefazolin (OR 2.07, 95% CI 1.15-3.73; p = 0.015). 

Conclusion: Cefazolin should be administered within 45 minutes of procedure initiation to best mitigate the odds of SSIs. Cefazolin was associated with a decreased odds of SSIs compared with clindamycin, supporting its use as the preoperative antibiotic of choice.

Self-assessment question: Based on the results of this trial, in what time frame should cefazolin be administered preoperatively to best mitigate the odds of SSIs?
A. 0 to 45 minutes
B. 45 to 60 minutes
C. 60 to 120 minutes
D. None of the above

Authors: Kyle Greenfield PharmD, Carina Mackarey Pharm D

Learning Objective: At the completion of this presentation, the participant will be able to identify components of pharmacist-led beta-lactam allergy assessment that support appropriate antibiotic selection.

Background: Many reported beta-lactam allergies represent low-to-moderate risk reactions that limit first-line therapy. This project evaluated whether pharmacist-led assessments could clarify allergy histories and support appropriate antibiotic selection.

Self-Assessment Question: Which finding most strongly supports safe beta-lactam use in a patient with a documented penicillin allergy?

Methods: This prospective quality improvement project was conducted at the Wilkes-Barre VA Medical Center from November 2025 through February 2026. Patients admitted to our medical unit (4E), ICU, or those scheduled for surgical procedures with a documented beta-lactam allergy were identified for pharmacist assessment. Patients were interviewed either in person during hospitalization or by phone prior to surgery to clarify the causative beta-lactam, the type of reaction, and any prior tolerance to other beta-lactams. VA and external pharmacy records were reviewed to identify previous beta-lactam exposures. Findings were documented in a standardized “Beta-lactam Allergy Assessment Note” and allergy records were updated when appropriate to support future antibiotic selection.
 
Results: A total of 42 patients with documented beta-lactam allergy labels were assessed including 10 surgical patients. Penicillin allergy labels were present in 36 patients (86%). All 10 surgical patients received clindamycin for prophylaxis; however, 5 (50%) had documented prior beta-lactam tolerance and could have safely received cefazolin. Following assessment, 9 patients (21%) had their allergies de-labeled, 30 (72%) were eligible for an oral amoxicillin challenge, and 3 (7%) required continued beta-lactam avoidance. Most patients (81%) had low-to-moderate risk reactions. Prior tolerance of at least one beta-lactam antibiotic was identified in 32 patients (76%) and 40 patients (95%) reported reactions occurring more than 10 years prior.

Conclusion: Pharmacist-led beta-lactam allergy assessment identified opportunities to clarify inaccurate allergy labels and support development of an oral amoxicillin challenge protocol. Most hospitalized patients were receiving appropriate beta-lactam therapy; however, opportunities to optimize pre-operative antibiotic selection were identified. Incorporating structured allergy evaluations into antimicrobial stewardship workflow may improve access to first-line therapies and optimize prescribing practices.

Title: Assessing clinical impact of coagulase-negative staphylococci blood cultures determined to be contaminants 
 
Authors: Morgan Mendes, PharmD; Michael Miller, PharmD, BCPS, BCIDP 
 
Objective: Identify appropriate antimicrobial stewardship strategies when coagulase-negative staphylococci blood cultures are determined to be contaminants. 
 
Self-Assessment Question: Which antimicrobial stewardship strategy is most appropriate when a positive blood culture is determined to be a contaminant in a clinically stable patient with no signs of infection? 
A. Continue vancomycin until repeat cultures are negative 
B. De-escalate or discontinue vancomycin after culture review 
C. Add gram-negative coverage 
D. Switch to daptomycin 
 
Background: Blood cultures are a tool for diagnosing sepsis, yet 1-2% represent contamination. Treating contaminants as true infections can lead to unnecessary antibiotic use and increased healthcare costs. 
 
Methods: This retrospective cohort study evaluated adults admitted to TidalHealth Peninsula Regional between October 1, 2023, and October 1, 2025, with a single positive blood culture for coagulase-negative staphylococci from the emergency department. Patients with risk factors for true bacteremia were excluded. The primary objective was to compare hospital length of stay between patients who continued vancomycin and those who did not receive or were de-escalated from vancomycin within 24 hours of contaminant culture identification. Length of stay was analyzed using a Mann–Whitney U test. Secondary outcomes included incidence of acute kidney injury and new infectious disease consults, analyzed using a Fisher’s exact or chi-square test as appropriate. 
 
Results: Of 449 patients reviewed, 281 met inclusion criteria. Median hospital length of stay was significantly shorter in the de-escalation group compared to the continued vancomycin group (2-day difference, 95% CI 1–3; p < 0.001). No patients in the de-escalation group experienced acute kidney injury compared to three patients in the continued group (0% vs 3.5%; p = 0.30). New infectious disease consults within 72 hours occurred more frequently in patients who continued vancomycin (34%) compared to those de-escalated (24.6%, p < 0.001). 
 
Conclusion: Early avoidance or de-escalation of vancomycin in patients with blood culture contaminants may reduce unnecessary antibiotic exposure and hospital length of stay. These findings support antimicrobial stewardship strategies focused on early culture review and targeted de-escalation. 

Authors: Tina Lin, PharmD; Eris Cani, BS, PharmD, BCIDP, BCPS; Lendelle Raymond, MS, PharmD, BCIDP, AAHIVP; Cosmina Zeana, MD, MPH; James Lin, PharmD; Kyoung-Sil Kang, PharmD, BCPS, BCOP; Momina Qureshi, PharmD  

Learning Objective: At the conclusion of my presentation, the participant will be able to describe the impact of a provider education on the rate of appropriate statin prescribing for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in people living with HIV (PLWH).

Background/Objective: People living with HIV have an increased risk of ASCVD. Despite guideline updates following the REPRIEVE trial, statins remain underutilized. This study evaluates whether provider education improves appropriate statin prescribing.  

Methods: This quasi-experimental pre–post pilot study used retrospective chart review of people living with HIV at an urban HIV clinic who are eligible for statin therapy per 2024 DHHS guidelines during pre- (January–August 2025) and post-intervention (November 2025–January 2026) periods. Patients aged 40–75 years were assessed for appropriate statin use based on guideline-recommended indications and statin intensity. The intervention included provider education through in-service sessions that reviewed guideline recommendations and key trial data. The primary outcome was the proportion of patients prescribed appropriate statin therapy pre- versus post-intervention. The secondary outcome was adherence to guideline recommendations stratified by the ASCVD risk category. The statistical analysis included descriptive statistics to summarize baseline characteristics and a Chi-square test for categorical data. A p-value of < 0.05 was considered statistically significant.  

Results: A total of 92 patients were included (44 in the pre-intervention group and 48 in the post-intervention group). The proportion of patients receiving appropriate statin therapy increased from 36.4% in the pre-intervention group to 60.4% in the post-intervention group (p= 0.021). When stratified by ASCVD risk category, the intermediate-risk group accounted for the majority of guideline-adherence statin prescribing in both the pre- and post-intervention periods (68.7% and 48.3%, respectively). Notably, statin therapy was initiated among patients in the low ASCVD risk group during the post-intervention period (24%).

Conclusion: The proportion of patients prescribed appropriate statin therapy improved following provider education. These findings support the use of provider education to enhance guideline adherence.  

Self Assessment Question: A 52-year-old Hispanic male with well-controlled HIV on ART presents for routine follow-up. LDL is 78 mg/dL. His estimated 10-year ASCVD risk is 6%. Based on the 2024 DHHS HIV guidelines, should this patient be started on statin therapy?  

A. Yes, statin therapy is indicated
B. No, statin therapy is not indicated

Title:
Ertapenem versus cefepime or other carbapenems for the treatment of AmpC-producing organisms

Authors:
Michelle Fuksman, PharmD; Antoinette Acbo, PharmD, BCIDP; Mary McKiever, PharmD; Sarah Valiante, PharmD, BCIDP

Learning Objective:
Compare the efficacy of select beta-lactams for the treatment of infections due to AmpC-producing organisms.

Self-Assessment Question:
Which of the following antibiotics would NOT be appropriate to treat Enterobacter cloacae bloodstream infection?

1. Cefepime
2. Imipenem
3. Piperacillin-tazobactam
4. Ertapenem

Background/Objective:
Ertapenem lacks data for the treatment of AmpC-producing organisms, but it is often used in clinical practice. This study aimed to investigate ertapenem for the treatment of AmpC-producing organisms compared to cefepime and other carbapenems.

Methods:
This retrospective, single center study evaluated ertapenem versus cefepime, meropenem, or imipenem for the treatment of AmpC-producing organisms. This study included adult patients given one of the study drugs as definitive therapy for AmpC-producing organisms from May 26, 2021 to June 30, 2025. Patients were excluded if they were pregnant, treated with over 72 hours of appropriate treatment before definitive therapy, treated with less than 72 hours of definitive therapy, expired within 48 hours of definitive therapy initiation, or if the pathogen was in stool culture only or resistant to definitive treatment. The primary endpoint was 90-day mortality. The secondary endpoints included 30-day mortality, clinical failure, microbiologic failure in patients with a positive blood culture, 30- and 90-day recurrence, and length of stay.

Results:
Across 216 patients, 96 received ertapenem, 86 received cefepime, 11 received imipenem, and 23 received meropenem. Ertapenem compared with cefepime, imipenem, or meropenem was not associated with increased 90-day mortality (22% versus 34%, 45%, and 39%, respectively; p=0.11) or increased 30-day mortality (17% versus 22%, 27%, and 39%, respectively; p=0.12). Microbiologic failure occurred in 1 case in the ertapenem group (1.0%; p>0.99). 30- and 90-day recurrence was comparable between treatments and occurred infrequently. In the meropenem and ertapenem groups, clinical failure (78% and 54% respectively; p=0.21) and median length of hospitalization (30 days and 23 days respectively; p=0.46) were not significantly different.

Conclusion:
Among patients with infections due to AmpC-producing organism(s), this data demonstrated no significant differences in ertapenem’s efficacy compared to cefepime, meropenem, or imipenem-cilastatin.

Authors: Jimin Jun, PharmD; April Finnigan, PharmD, BCCCP; Natalie Atkin, DO; Stefan Leichtle, MD, MBA; Lois Lee, PharmD, BCPPS, BCIDP
Learning Objective: Audience members will be able to describe how implementation of a health system-developed guideline promotes consistent, evidence-based prophylactic antibiotic selection and duration for open fracture injuries. 
Background/Objective: Recent literature reports variability in prophylactic antibiotic practices for open fractures despite guidelines and stewardship efforts. This study describes how an institutional guideline supports antimicrobial stewardship and patient outcomes.
Methods: This retrospective analysis included patients treated at a single tertiary care hospital from January 2022 through May 2025. Of 500 participants who received prophylactic antibiotics for open long bone fractures, 186 were analyzed; those discharged within 72 hours or undergoing extremity amputation were excluded. The study evaluated antibiotic patterns before and after the implementation of the system guideline in May 2024. The primary outcome was days of therapy for prophylactic antibiotics. The secondary outcomes included time to targeted therapy, protocol adherence in the post-implementation group, and trauma site infection incidence. The primary outcome was reported as a median with interquartile ranges and analyzed using Mann Whitney U, with statistical significance defined as a p-value less than 0.05. Secondary outcomes were reported as descriptive statistics with statistics completed using a chi-square test. 
Results: The primary endpoint, median duration of therapy, was significantly shorter after the implementation of a standardized institution guideline, decreasing from 2 days pre-guideline to 1 day post-guideline. Median time to targeted therapy was similar between groups (12 minutes pre-guideline vs. 11 minutes post-guideline). Regarding safety outcomes, surgical site infections occurred in 9.7% of pre-guideline patients and 11.8% of post-guideline patients. Overall guideline adherence in the post-guideline group was 77.4%.
Conclusions: This study demonstrates the antimicrobial stewardship impact of implementing a hospital guideline to standardize antibiotic prophylaxis for open fracture injuries. A concurrent reduction in broad-spectrum antibiotic utilization, particularly piperacillin–tazobactam, further supports its stewardship benefit. Findings highlight the need for improved standardization and monitoring strategies for type III injuries, where guideline noncompliance was most frequent.
Self-Assessment Question: What practice gap can an institution-derived guideline for antibiotic prophylaxis in open fracture injuries primarily address? 
Self-Assessment Answer: a) Variability in timing of surgical intervention, b) Inconsistency in antibiotic duration and selection, c) Under-recognition of surgical site infections, d) Limited access to broad-spectrum antibiotics

Title: Impact of documented beta-lactam allergy on surgical antimicrobial prophylaxis selection in cesarean delivery

Authors: Catherine Herman, PharmD; Corey Medler, PharmD, MPH, BCIDP; Lindsay Donohue, PharmD, BCIDP 

Learning Objective: At the conclusion of my presentation, audience members will be able to describe how β-lactam allergy documentation can influence surgical antimicrobial prophylaxis (SAP) choice and timing in cesarean deliveries. 

Background/Objective: Although cefazolin’s unique R-1 side chain makes cross-reactivity with other β-lactams rare, this study evaluates whether documented β-lactam allergy affects SAP choice and timing in cesarean deliveries. 

Methods: This single-center, retrospective, cross-sectional study included adult patients (≥ 18 years) who underwent cesarean delivery at a large academic medical center in central Virginia from June 1, 2024 to May 31, 2025. Patients receiving antibiotics for treatment of active infection were excluded. The primary endpoint was the percentage of patients with a documented β-lactam allergy who received inappropriate SAP, encompassing both agent selection and timing. Secondary endpoints included inappropriate SAP amongst all cesarean delivery patients, incidence of suspected surgical site infection (SSI), postoperative acute kidney injury (AKI), and Clostridioides difficile infection (CDI). Data were collected through manual electronic medical record review and analyzed using descriptive statistics, chi-square, and Fisher’s exact tests. 

Results: Of 208 patients included, 104 had a documented β-lactam allergy and 104 did not. Most documented allergens were penicillins (>80%); 2 patients reported a cefazolin allergy. IgE-mediated reactions were most common (46%), followed by mild reactions (41%). Inappropriate SAP occurred in 22.1% of patients with a documented β-lactam allergy vs. 11.5% in non-β-lactam allergy patients (OR 2.18, p = 0.041). This was driven by higher rates of inappropriate agent selection (14.4% vs. 1.9%; OR 8.60, p = 0.001) and timing (21.2% vs. 10.6%; OR 2.27, p = 0.037) in β-lactam allergy patients. Suspected SSI occurred in 6.7% of patients, with no significant difference by allergy status or agent appropriateness. No postoperative AKI or CDI were identified. 

Conclusions: Documented β-lactam allergy was associated with a higher rate of inappropriate SAP selection and timing, driven largely by unnecessary avoidance of cefazolin. These findings highlight opportunities for β-lactam allergy evaluation and de-labeling, optimization of perioperative order sets, and integration of decision-support tools to improve antimicrobial stewardship in cesarean deliveries. 

Self-Assessment Question: True/False: A documented β-lactam allergy was associated with significantly higher odds of inappropriate SAP, even though most patients could have safely received cefazolin.

Title : Clinical outcomes of full-dose vs. renally adjusted oral beta-lactams in gram-negative bloodstream infections

Authors : Sadaf Gharibi, PharmD; Sarah Valiante, PharmD, BCIDP; Samantha Stewart, PharmD, BCOP; Antoinette Acbo, PharmD, BCIDP

Objective: Assess the effect of oral beta-lactam dosing on 90-day all-cause mortality and other clinical outcomes in patients with gram-negative bloodstream infections (GN BSI)

Self assessment question: 

• Which of the following patients would be the best candidate for transition from intravenous therapy to oral cefuroxime for gram-negative bloodstream infections?
• A) In the ICU on norepinephrine drip
• B) Clinically stable after > 48 hours of IV antibiotic, tolerating oral intake
• C) Intra-abdominal abscess without source control 
• D) ESBL-producing organisms not susceptible to available oral beta-lactams

Background: Studies suggest that the higher recurrence with oral beta-lactams (BL) in treating GN BSI may be due to suboptimal dosing and preserved renal function. This study evaluates the effect of oral (PO) BL dosing on clinical outcomes.

Methods: This single center retrospective study was conducted from January 2025 to June 2025. The primary outcome was 90-day all-cause mortality in patients with GN BSIs treated with full dose versus renally adjusted PO  BL. Secondary outcomes included 90-day hospital readmission, relapse of bloodstream infection at 90 days, total intravenous (IV) and PO antibiotic days, and length of hospital stay. Patients included were adults with GN BSI treated with PO step down BL following at least 48 hours of empiric IV therapy. Exclusion criteria included complicated infections requiring prolonged IV therapy, concomitant use of non-BL PO antibiotics active against the index isolate, received PO BL to which the index organism in blood or other culture was not susceptible, and expiration within 48 hours of appropriate therapy. PO antibiotic use trends were also evaluated.

Results:
Among the 237 included patients (Median age: 74, 123 male (51.9%), 202 patients had good renal function and 37 patients had bad renal function. The primary outcome (90-day all-cause mortality) occurred in 5 patients with good and 5 patients with bad renal function, and good renal function was associated with significantly lower odds of 90-day all-cause mortality compared with bad renal function (OR:0.10, 95% CI 0.01-0.73, p=0.025). No significant association was observed for 90-day readmission (OR 0.51, 95% CI 0.20-1.26, p=0.145) or recurrence (OR 0.91, 95% CI 0.13-7.89, p=0.921). Antibiotic dosing strategy (dose-adjusted vs. full dose) was not significantly associated with any of the outcomes.

Conclusion:
In this retrospective study of adults with GN BSI treated with PO step down BL, the odds of 90-day all cause mortality was significantly lower in patients with good renal function. No significant difference was observed in the rate of 90-day readmission or recurrence among groups. Collectively, the result of the study suggested that dosing strategy of PO BLs (full dose vs renally dose adjusted), may have no impact on 90-day mortality, hospitalization and recurrence in patients with GN BSI.

• Title: Duration of antibiotic therapy for hospital-acquired pneumonia and ventilator-associated pneumonia: a single-center, retrospective cohort study of five versus seven days of therapy
• Authors: Tejona Johnson-Moore, PharmD; Olubusola Fowowe, PharmD, BCIPD; Sarah Graziose, PharmD, BCPS, BCID
• Learning Objective: Evaluate the impact of using a shorter versus standard antibiotic therapy for hospital-acquired and ventilator-associated pneumonia
• Background/Objective: This study’s objective is to assess whether reducing the antibiotic treatment duration to 5 days yields similar clinical outcomes as 7 days of antibiotic therapy in patients with hospital-acquired pneumonia and ventilator-associated pneumonia.
• Methods: This retrospective, single-center cohort study was conducted at a level one trauma and academic center and included patients diagnosed with hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP) between January 1, 2023, and August 31, 2025. The primary outcome was 30-day mortality, with secondary outcomes including recurrent pneumonia, in-hospital mortality, and adverse events. Secondary outcomes included recurrent pneumonia, in-hospital mortality, and 30-day all-cause mortality. Enrolled patients were adults at least 18 years old with a clinical diagnosis of hospital-acquired or ventilator-associated pneumonia who were receiving appropriate antibiotic therapy according to the micro-organism
• Results: There were 144 patients that met the inclusion criteria. Among the 144 patients diagnosed with pneumonia, 119 had 7 days of antibiotic therapy, while 25 had 5 days. At 30 days, no difference in mortality was observed between the 5-day and 7-day therapy groups. However, non-inferiority could not be demonstrated. Findings were consistent across adjusted and sensitivity analyses.
• Conclusion: According to the study’s findings, 5-day antibiotic therapy can’t be concluded to have similar clinical outcomes as patients on a 7-day regimen needed for hospital-associated pneumonia and ventilator-associated pneumonia. Using a shorter antibiotic course is a potential option for clinically improving individuals. However, it is not suggested that it should be in place of using a 7-day course for pneumonia eradication
• Self-assessment Question: Based on this study’s results, which of the following represents the most appropriate clinical application for patients diagnosed with either HAP or VAP?
• A. All patients diagnosed with HAP and VAP should be given 5 days of therapy
• B. Continue the 7-day antibiotic therapy as the standard regimen, with consideration of using a 5-day treatment duration in patients demonstrating clear clinical improvement
• C. Avoid using 5-day antibiotic regimens in patients diagnosed with either HAP or VAP
  

Authors: Victor E. Rojas Velazquez, Pharm.D., Rachel Savilla, Pharm.D., Nicole McCoy, Pharm.D., Safiyyah Mitchell, Pharm.D., Brian Burton, MS
Learning Objective: Identify areas where clinical pharmacists can serve a critical role in CMV prophylaxis dosing adjustments and rationale
Background/Objective: Studies have shown that pharmacist implementation can lead to minimization of adverse events in immunosuppression management. The aim of this study was to evaluate the impact of an outpatient transplant pharmacist on CMV prophylaxis appropriateness.
Methods: Medical records were reviewed as a retrospective cohort study of kidney transplant recipients at Charleston Area Medical Center between January 2024 and June 2025. Comparing outcomes before and after implementing a pharmacist-led intervention, stratification of cohorts was decided by initiation date of clinical pharmacist. Data collected consisted of renal function to assess appropriateness of CMV prophylaxis dosing, incidence of breakthrough CMV, other infections, bacteremia, graft, and patient survival using data up to 3 months post-transplant.
Results: CMV appropriateness was assessed for 76% of the 128 patients studied. A greater portion of patients were included in the control arm compared to the treatment arm (n = 59 versus 39). Statistical analysis for the appropriateness of renal dose adjustments between the two cohorts detected no difference when viewed from discharge up to 3 months post-transplant. Unexpectedly, renal dose adjustments between the cohorts during discharge showed statistical significance towards the control (0 versus 12.82% inappropriately adjusted, p = 0.0089). Secondary outcomes such as bacteremia (p = 0.4), other infections (p = 0.7) biopsy proven rejection (p = 0.4) showed no difference.
Conclusions: Lack of statistical significance for appropriate renal dose adjustments shown is likely due to limitations of retrospective analysis rather than lack of clinical significance. Statistical significance of the patients captured at discharge was attributed to multiple factors that were not accounted for during data analysis. Nonetheless, a positive trend for appropriate renal dose adjustments favored the post-pharmacist group, signifying potential benefit of the clinical pharmacist’s role.
Self- assessment question: What gaps can clinical transplant pharmacist focus on to avoid potential unwanted effects of non-renally dose adjusted valganciclovir?

Authors: Maksudul Mowla, PharmD, Clint Borja, PharmD, BCIDP, Nicole Harrington, PharmD, BCIDP, BCPS-AQ ID, Jennifer Wolf, PharmD, BCIDP

Objective: Audience members will be able to describe the impact of stricter UARC criteria on discontinuation of antibiotics for urinary tract infection (UTI).

Background: The UARC criteria at ChristianaCare were modified to only reflex to culture if white blood cells >10 cells/hpf are present. An internal study showed a 15.2% reduction in urine cultures performed after implementation of the modified criteria.

Methods: This single-center retrospective study is an extension of the previous internal study to evaluate the impact of the modified UARC criteria on antibiotic discontinuation. Patients from the internal study who are ≥ 18 years old with an UARC performed, and an antibiotic ordered within 24 hours of an UARC order were included. Key exclusion criteria include pregnancy, transplant patients, an absolute neutrophil count of < 1000 cells/mm3, and patients receiving antibiotics for another indication.
The primary outcome is the percentage of patients with antibiotics discontinued within 24 hours of an UARC result. Key secondary outcomes include the percentage of antibiotic discontinuation within 48 hours of an UARC result, and within 24 hours of a negative urine culture.
A Chi-square test was performed to compare the primary and secondary outcomes.

Results: A randomized sample of 950 patients from the internal study was evaluated. Of these, 75 patients in the pre-cohort and 78 in the post-cohort met inclusion criteria.
The percentage of patients with antibiotics discontinued within 24 hours of an UARC result was 20% vs 23% (p = 0.64) in the pre- and post-cohort, respectively. At 48 hours, antibiotic discontinuation was 44% vs 50% (p = 0.46) between the two groups. In patients whose UARC did reflex to culture, antibiotics were discontinued within 24 hours of a negative urine culture in 67% vs 68% (p = 0.91) of patients. Stand-alone urine cultures were ordered despite a negative UARC for 2 patients in the pre-cohort and 6 in the post-cohort.

Conclusion: There was no statistical difference in the percentage of antibiotic discontinuation, though it was slightly higher in the post group (3% at 24 hours and 6% at 48 hours). These findings maybe impacted by study limitations including a small sample size and possible randomization bias. Antimicrobial stewardship principles do highlight the potential benefit of a more stringent UARC criteria, and the need for a robust analysis that includes evaluation of clinical rationale for antibiotic prescribing.

Self Assessment Question: Does the implementation of a more stringent UARC criteria always result in antibiotic discontinuation for UTI?

• True
• False