2026 Eastern States Conference

• Title: Standardization of Tablet Splitting Workflows at JHHS
• Authors: Eric Mackin, PharmD; Ian Watt, PharmD; Emily Pherson, PharmD, BCPS; Rosemary Duncan, PharmD, BCPS; Lisa Hutchins, PharmD, BCPPS; Dave Stimler, PharmD, MBA
• Objective: Audience members will be able to outline the steps used to develop a standardized split tablets workflow across a health system.
• Self Assessment Question: Which of the following is a benefit of standardizing split tablet practices across a health system?
  1. A. Clear accountability across departments
  2. B. Automatic selection of dispense code in EHR when dispensing split tablets
  3. C. Reduced variability for employees who work at multiple sites
  4. D. Decreased manual manipulation of orders on verification and reverification
  5. E. All of the above
• Background: The purpose of this project is to gain consensus among Johns Hopkins Health System hospital sites on the preferred practice for splitting tablets, i.e., when tablets should be split in the pharmacy prior to dispensing or split by a nurse on the unit.
• Methods: The objective of this project is to develop a workflow for splitting tablets that aligns Johns Hopkins Health System (JHHS) and allows for the implementation of enhancements to the EHR (Epic). To accomplish this, the project team confirmed current workflows for all JHHS hospitals, surveyed other hospitals and health systems to determine common practices, and gathered data on all enteral dispenses across JHHS in October 2025 using Epic SlicerDicer. This data was then analyzed in Microsoft Excel to quantify total enteral dispenses, dispenses that require splitting a tablet, repackaged doses dispensed, number of split dispenses for which a commercially available tablet exists for the intended dose, and most frequently split medications. A summary of the data was presented to a health system-level Automation and Operations Committee, and stakeholders from each hospital collaborated to gain consensus on the newly aligned workflow.
• Results: JHHS hospitals initially reported varied split tablet workflows, ranging from pharmacy staff splitting all tablets to nurses splitting all tablets. JHHS hospitals also reported differences in prepackaging practices (unit dose packaging a pre-split tablet). Surveys of other health systems revealed no standard tablet-splitting practice. In October 2025, 2.2% of all enteral dispenses required splitting a tablet, with 28.7% being dispensed from pharmacy and 71.3% dispensed from ADC. Data analysis showed that this number could be further decreased by purchasing the lowest commercially available strength of more medications and increasing prepackaging practices. After discussion, the workgroup came to consensus on option 3: pharmacy staff split all tablets dispensed from the pharmacy; nursing staff split all tablets dispensed from the ADC. Pharmacy staff will also minimize the number of dispenses that require splitting by optimizing prepackaging and purchasing practices.
• Conclusion: No national standard exists for tablet splitting workflows, creating variance in practice and complicating EHR optimization. JHHS pharmacies were able to come to consensus on a new workflow that works for all hospitals by assessing the objective impact of each potential new workflow and developing solutions that emphasize safety, accuracy, and efficiency.

Title:
Midodrine use in hospitalized patients: a retrospective evaluation of prescribing practices and discharge continuation at a community hospital
Authors:
Harshini D Sobhan, PharmD, MSHS, Ruxandra Necula-Lee, PharmD, Maricelle Monteagudo-Chu, PharmD, BCIDP, BCPS, Shamsul Islam, PharmD, MBA
Learning Objective:
Audience members will be able to evaluate inpatient prescribing practices of midodrine and identify opportunities for optimization of use and improved transitions of care.
Background:
Midodrine is approved for symptomatic orthostatic hypotension, is frequently used off-label. This study evaluates indications, dosing, frequency, and duration of use, comparing new inpatient initiation versus continuation from home and at discharge.
Methods:
Retrospective chart review of adult patients (at least 18years old) admitted to the hospital, with an active inpatient midodrine order during January 1, 2025, to March 31, 2025. Excluded patients were seen in the Emergency Department and not admitted as inpatients, midodrine use less than 24 hours, and those who had additional visits during the study period. Data collected included demographics, indication for use, initiation type, duration of therapy, and discharge continuation. Descriptive statistics summarize patient and prescribing characteristics. Primary outcome is to evaluate the frequency of midodrine use based on indication, distinguishing between new inpatient start and home-medication continuation. Secondary outcome is to evaluate the duration of therapy, continuation of use at discharge and baseline systolic blood pressure prior to first dose for standing hypotension orders. 
Results:
A total of 179 patient charts were reviewed, with 119 patients included. The most common indications for midodrine use were hypotension outside the ICU (59.2%) and ICU hypotension for vasopressor sparing (29.4%). The average duration of therapy was 8.62 days + 9.77. Midodrine was used prior to admission in 31.9% of patients and newly initiated in 68.1%, with 40.7% of new starts occurring in the ICU. Among newly initiated patients, 22.2% continued therapy at discharge, including 12.1% of ICU patients. For hypotension orders outside the ICU, 74.6% were standing and 25.4% were as needed. Among standing orders, 87.2% had a specified systolic blood pressure (SBP) ≤ 120 mmHg, while 12.8%  specified SBP > 120 mmHg prior to start of therapy.
Conclusions:
Midodrine is commonly used to treat hypotension in the ICU and non-ICU settings. In our study, at least 20% of patients who started on midodrine during hospitalization were continued on therapy at discharge. We observed various ranges of blood pressure parameters within midodrine orders outside of the ICU settings, highlighting the importance of improved transitions of care. Further evaluation is needed to determine if standardization of parameters within the midodrine record is warranted.
 
 
Self-Assessment Question
Which pharmacist-driven strategy is best supported by this study to improve safe and appropriate inpatient midodrine use?
A. Encouraging routine continuation of midodrine at discharge for all ICU-started patients
B. Performing medication reconciliation with targeted reassessment of midodrine indication and duration
C. Limiting midodrine initiation to nephrology consults only
D. Avoiding midodrine use in patients with any history of hypotension

Evaluating the effect of parenteral phosphate dose on serum phosphorus level in pediatric patients

Eric Dodson, PharmD, Amanda Clouser, PharmD, BCPPS, Pooja Shah, PharmD, BCPPS, Molly Siver, PharmD, BCOP

Learning Objective
At the conclusion of my presentation, participants will be able to describe the effect of parenteral phosphate supplementation dose on serum phosphorus levels in the pediatric patient population.
Objective
This study is designed to evaluate the effect of parenteral phosphate dosing on serum phosphate concentration by evaluating current dosing practices 
Background/Objective
There is a current paucity of data regarding the dosing of parenteral phosphate in the pediatric patient population. 
Methods
This is a single center retrospective chart review evaluating infants, children and adolescents admitted in a children’s hospital within an adult institution who received parenteral intermittent sodium or potassium phosphate from August 2012 - August 2025. The primary outcome is to evaluate the effect of parenteral phosphate dose on the change in serum phosphorus concentration in the pediatric patient population. Secondary outcomes include the need for resupplementation within 24 hours of a repeat phosphorus level, the number of doses and amount of time required to achieve a serum phosphorus level > 2 mg/dL and the incidence of hyperphosphatemia as a result of current parenteral phosphate dosing strategies.
Results
Of the 152 patients screened, 109 patients were included in the study across 164 administrations of parenteral phosphate. The mean change in serum phosphorus (SD) for the entire study population was  0.53 mg/dL (± 0.98). The mean change in serum phosphorus in the low, medium, high, and very high dose groups were 0.65 mg/dL (± 0.71), 0.53 mg/dL (± 0.78), 1.05 mg/dL (± 1.07), and 1.59 mg/dL (± 1.66) respectively. Persistent hypophosphatemia occurred in 134 (81.8%) administrations, while hyperphosphatemia occurred in 4 (2.4%) of administrations.
Conclusion
Statistical analysis for this study is still ongoing, though descriptive statistics for the primary outcome appear to show a linear relationship between parenteral phosphorus dose and change in serum phosphorus concentration. Given the high rates of persistent hypophosphatemia seen in this study across all dosing ranges, it may be appropriate to consider higher phosphate dosing in the pediatric population, however, further studies may be needed to elucidate the ideal dosing regimen based on serum phosphorus level.
Self-Assessment Question
Which of the following medication classes are a major risk factor for the development of hypophosphatemia? Select all that apply.

Title: 
Combination therapy for carbapenem-resistant Acinetobacter baumannii infections: what is the optimal regimen?
Authors: 
Hyun Ju Abigail Yoon, PharmD; Patrick Lake, PharmD, BCIDP; Siddharth Swamy, PharmD, BCIDP; Yen-Hong Kuo, PhD; Rani Sebti, MD
Objective: 
Audience members will be able to compare treatment outcomes of various multi-drug regimens for infections due to carbapenem-resistant Acinetobacter baumannii.
Self Assessment Question: 
Which of the following are appropriate treatment options for CRAB infections?
A. Sulbactam-durlobactam plus meropenem
B. Ceftriaxone plus azithromycin
C. Cefepime plus metronidazole
D. Piperacillin-tazobactam plus linezolid
Background: 
The objective of this study was to compare the treatment outcomes of sulbactam-durlobactam- and cefiderocol-based combinations for the treatment of carbapenem-resistant Acinetobacter baumannii (CRAB) infections.
Methods: 
This was a multicenter retrospective study. Patients were included if they were hospitalized between October 2020 and November 2025, had infections due to CRAB, and received one of the following combination antimicrobial regimens as targeted therapy for a minimum of 72 hours. Antimicrobial regimens included sulbactam-durlobactam-based regimens (excluding cefiderocol), and cefiderocol-based regimens (excluding sulbactam-durlobactam). Outcomes were compared in each treatment group. The primary outcome was clinical failure. Clinical failure was defined as in-hospital mortality, an escalation in antimicrobial therapy, or an incomplete duration of therapy. Secondary outcomes included in-hospital mortality, duration of therapy, escalation of therapy, and microbiologic cure (only for bloodstream infections). 
Results:
Of 396 patients screened, 186 were included: 165 in the cefiderocol arm and 21 in the sulbactam-durlobactam arm. Median Charlson Comorbidity Index scores were 6 and 5, respectively, indicating high baseline mortality risk. Pneumonia was the most common infection, followed by bloodstream infections. Cefiderocol monotherapy (67.9%) and sulbactam-durlobactam plus meropenem (61.9%) were the most common regimens. Clinical failure occurred in 20.6% versus 14.3% (p=0.82), respectively. In-hospital mortality was higher in the cefiderocol group (17.6% vs 0%). No significant differences were observed in primary or secondary outcomes.
Conclusion:
There was no significant difference in clinical failure between cefiderocol- and sulbactam-durlobactam-based regimens. However, the cefiderocol arm had a higher rate of in-hospital mortality. Given the mortality imbalance between groups and the predominance of cefiderocol monotherapy, further studies are warranted to evaluate the role of cefiderocol monotherapy versus combination therapy in CRAB infections.

Authors: Jaden Wills, PharmD; Kevin Pritt, PharmD, BCPS
Learning Objective: Determine if a pharmacist-led medication reconciliation and discharge counseling pilot program affects thirty-day all-cause readmission rates in specific patient subsets admitted to a general medicine unit.
Self-Assessment Question: Does pharmacist-led medication reconciliation during transitions of care, compared to standard nurse-led medication reconciliation, reduce 30-day hospital readmission rates?
Background: Hospital readmissions are a significant driver of healthcare utilization. This study assessed the impact of a novel, pharmacist-led medication reconciliation and discharge counseling during care transitions on thirty-day hospital readmission rates.
Methods: This pre-post retrospective study evaluated the impact of pharmacist-led medication reconciliation and discharge counseling on adult patients with a heart failure (HF) diagnosis (new onset or acute exacerbation) or those insured through Peak Medicare Advantage at an acute care hospital. The pre-intervention group included patients who received standard nurse-led medication reconciliation prior to November 1st, 2025. The post-intervention group included patients admitted after November 1st, 2025, and discharged prior to February 8th, 2026. The primary outcome was thirty-day readmission rates. Secondary outcomes included the number and class of medication interventions, provider acceptance rate, and proportion of patients receiving both medication reconciliation and discharge counseling. Data was collected using a secure Microsoft Excel spreadsheet and analyzed using descriptive statistics.
Results: Thirty patients were included in both the pre- and post-implementation groups. Thirty-day readmissions in the heart failure cohort decreased from 23.3% to 18.5% after implementation of pharmacist-led medication reconciliation and discharge counseling. PEAK readmission data is currently being collected and analyzed. Pharmacist involvement increased discrepancies discovered per patient (3.8 vs. 2.7) and achieved a 100% resolution rate compared to 70% in the pre-intervention group. The most common discrepancy in both groups was “patient not taking”. Notably, unintentional omission (n=13) and incorrect dose (n=6) were identified only in the pharmacist group. Discharge counseling rates increased by 10% post-implementation.
Conclusion: A structured, pharmacist-led care transition program is a vital component to reducing thirty-day readmission rates while also identifying and resolving clinically relevant medication discrepancies, particularly omissions and dose errors. The review’s findings emphasize both the clinical value and potential cost avoidance associated with integrating pharmacists into care transition programs. Future research should target larger populations, additional patient groups, and a prospective approach.

Title 
Advancing antimicrobial stewardship by streamlining pharmacist management of culture results through implementation of a collaborative practice agreement in a community hospital emergency department: post implementation assessment  

Authors 
Dasia Simmons, PharmD 
Benjamin Miles, PharmD, BCPS, BCEMP  
Mandana Eimen, PharmD  
Christopher Keeys, PharmD, BCPS 
Paul Norris, PharmD 

Background/Objective 
To evaluate post-implementation outcomes of a pharmacist-driven antimicrobial stewardship model for post-discharge culture review in the emergency department, where patients are often discharged prior to availability of final microbiology results. At Sibley Memorial Hospital, a collaborative practice agreement supports pharmacist-led review, with prior data demonstrating predominantly no-change interventions alongside a subset of clinically actionable modifications, including correction of drug–bug mismatches and initiation of therapy for previously untreated infections. 

Methods 
A post-implementation assessment will be conducted to further define the scope and nature of pharmacist interventions, characterize their clinical significance, and identify opportunities for improvement. The analysis will evaluate patterns of drug–bug mismatches, assess cases requiring no change to determine appropriateness of therapy versus contamination or colonization, and examine cases requiring new antibiotic initiation to identify factors contributing to lack of initial treatment, including ED readmissions. Additionally, infection-specific trends associated with antibiotic changes will be analyzed, and any variations from the collaborative practice agreement will be documented. 

Conclusion 
This post implementation assessment  is expected to further  characterize the clinical relevance of pharmacist-led interventions,  identify opportunities to optimize antimicrobial stewardship efforts,  improve post-discharge outcomes in the ED setting, and meet regulatory compliance ensuring pharmacist interventions are consistently aligned with the approved collaborative practice agreement in the District of Columbia.

Title: Outcomes associated with anticoagulation in cardiothoracic surgery patients with post-operative thrombocytopenia
Authors: Nada Daoud, PharmD; Corinne Whiteman, PharmD, BCCCP; Karishma Patel, PharmD
Objective: Audience members will be able to describe the incidence of heparin-induced thrombocytopenia (HIT) in cardiothoracic (CT) surgery patients.
Self-assessment question: True or False? Patients who develop thrombocytopenia while on heparin should be switched to a non-heparin anticoagulant regardless of their 4T score.
Background: When HIT is suspected, a 4T score is calculated and heparin is switched to a non-heparin anticoagulant. This study aimed to assess the incidence of HIT in post-operative CT surgery patients and evaluate the safety of argatroban.
Methods: This is a retrospective, single-center cohort study with data collected from January 2020 to July 2025. Post-operative CT surgery patients were eligible for inclusion if they had a platelet factor 4 enzyme-linked immunosorbent assay (PF4 ELISA) and/or serotonin release assay (SRA) HIT panel ordered within 30 days after surgery. Patients were excluded if they did not receive anticoagulation, had a prior history of HIT, were less than 18 years of age, or were pregnant. The primary outcome was the incidence of SRA-confirmed HIT. Secondary outcomes included intensive care unit (ICU) and hospital length of stays, 90-day mortality, time to therapeutic activated partial thromboplastin time (aPTT), and incidence of thrombocytopenia. Safety outcomes were the incidence of hepatotoxicity, bleeding, and thrombosis. Categorical data was reported as percentages, and continuous data was expressed as medians with interquartile ranges.
Results: A total of 54 patients were reviewed for eligibility, and 28 patients were included. Twenty-four hours after a HIT panel was ordered, 11 patients were not on anticoagulation, 11 were on heparin, and 6 were on argatroban. One patient met the primary outcome of having SRA-positive HIT (3.6%). Coronary artery bypass grafting (CABG) was the most common type of CT surgery in all three groups. Patients in the heparin group had longer hospital length of stays (23.7 [28.6] days) compared to those in the argatroban (17.3 [24.5] days) and no anticoagulation groups (19.5 [17.1] days). Patients on argatroban experienced more hepatotoxicity (83% vs. 75% vs. 67%) and bleeding events (100% vs. 63% vs. 83%) than those on heparin and no anticoagulation.
Conclusions: The low incidence of SRA-confirmed HIT suggests that post-CT surgery patients may develop thrombocytopenia due to risk factors other than heparin use. Switching from heparin to a non-heparin anticoagulant may be inappropriate in patients with a low 4T score and result in adverse events, as patients on argatroban experienced more hepatotoxicity and bleeding. Larger studies are needed to further define the incidence of HIT in CT surgery patients and the impact of argatroban on patient outcomes.

Title: Evaluation of therapeutic enoxaparin dosing strategies in hospitalized patients with morbid obesity

Authors: Huelena Nguyen, PharmD; Nina Jacob, PharmD, BCPS; Priya Shah, PharmD, BCPS; Jessica Roth, PharmD, BCPS, CDCES; Shannan Shelton, PharmD, BCACP

Objective: Identify differences in bleeding outcomes between standard (1-1.5 mg/kg) and reduced (<1 mg/kg) therapeutic enoxaparin dosing in patients with morbid obesity

Self Assessment Question: Which of the following statements is true regarding therapeutic enoxaparin dosing in patients with morbid obesity?

1. Reduced dosing is consistently recommended due to increased bleeding risk 
2. Standard dosing may still be appropriate despite concerns for bleeding 
3. Anti Xa monitoring has no utility in obesity 
4. Dosing is similar in patients with obesity compared to patients of normal weight 

Background: The objective of this study is to compare bleeding outcomes between standard and reduced dosing strategies in hospitalized adults with morbid obesity treated for venous thromboembolism

Methods: This multicenter, retrospective, observational case-cohort study evaluated adult inpatients ordered enoxaparin from the therapeutic enoxaparin dosing order set between July 1, 2023 to June 30, 2025 at ChristianaCare hospitals. Patients were included if they were at least 18 years old and had a body mass index (BMI) ≧40 kg/m2 or weight ≧150 kg and received at least 24 hours of therapy, while patients with a creatinine clearance <30 mL/min, intensive care unit admission, pregnancy or postpartum, recent trauma, known bleeding disorders, thrombocytopenia, cirrhosis, or history of heparin induced thrombocytopenia were excluded. Data collected included weight, enoxaparin dose, indication, concomitant medications, anti-Xa levels, and clinical outcomes, including major bleeding, minor bleeding, and thrombotic events. Descriptive statistics were used to evaluate baseline characteristics and categorical outcomes were compared using chi-square tests.

Results: A total of 1566 patients were screened, and 116 patients met inclusion criteria. The primary outcome is the proportion of major bleeding events during therapy and within 24 hours of discontinuation. Four major bleeding events (3.96%) occurred in the standard dose group compared to one event (6.67%) in the reduced dose group (p=0.506). Secondary outcomes include the proportion of minor bleeding events, therapeutic anti-Xa levels, and characterization of reduced dosing in patients with morbid obesity. Three minor bleeding events (2.87%) occurred in the standard dose group, and three events (20%) occurred in the reduced dose group (p=0.028). There was an inability to determine statistically significant differences for the remaining outcomes.

Conclusion: These findings suggest that there may be a difference in bleeding events between standard and reduced dosing strategies. The results of this study will provide insight into prescribing patterns of therapeutic enoxaparin in patients with morbid obesity and evaluate the safety of reduced dosing strategies. This will help support optimization of treatment guidelines in this high-risk population, but still highlights the need for ongoing evaluation in patients with BMI ≥40 kg/m².

Evaluation of AUC vs. Trough-Based Vancomycin Dosing in the Outpatient Setting
Lauren Yates, PharmD; Adam Archer, PharmD, BCIDP; SungHo Park, PharmD 
 
Learning Objective  
Audience members will be able to identify key benefits of area-the-under-curve-based vancomycin dosing in the home health setting.  

Background/Objective
The primary objective of this study was to evaluate the safety, efficacy, and utility of using Bayesian-software-assisted 24-hour area-the-under-curve (AUC24) monitoring to dose vancomycin compared to trough-based dosing in the home infusion setting.   

Methods  
This single-center, retrospective, quasi-experimental pre-post study included patients ≥18 years old who were discharged on ≥ 7 days on intravenous vancomycin and enrolled in our institutional outpatient parenteral antimicrobial therapy (OPAT) monitoring program. Exclusion criteria included outpatient labs delayed by more than 14 days at any point in therapy. The primary endpoint was the incidence of acute kidney injury (AKI), defined as ≥ 0.5 mg/dl or ≥ 50% increase in serum creatinine from baseline within 7 days. Efficacy endpoints include 90-day all-cause mortality, infection-related 30-day readmission, and change in antibiotic therapy due to clinical worsening. Utility endpoints include the number of labs collected during outpatient therapy. Data was collected via manual chart review and included baseline demographics, renal function, infection characteristics, concomitant nephrotoxic medications, and vancomycin regimen details.   

Results
This study found that AUC-based vancomycin monitoring significantly reduced the risk of nephrotoxicity in the outpatient setting. A total of 258 patients' encounters were screened with 158 meeting inclusion criteria, which yielded 79 patients in both the AUC and trough monitoring cohorts. Baseline characteristics were well matched between groups. AUC-guided dosing significantly reduced the rates of AKI compared to trough-based dosing (7.6% vs 24.1%), corresponding to a risk ratio of 0.32 (95% CI 0.13–0.75; p=0.005). The median number of labs per weeks of therapy was significantly reduced in the AUC arm (0.95 vs. 1.22, p<0.001), resulting in an average cost saving of $450 per week.    
 
Conclusion
This study observed a significant reduction in AKI with AUC-guided vancomycin therapeutic drug monitoring in the home health setting, supporting guideline recommendations favoring AUC over trough-based monitoring in a patient population with limited data. As outpatient lab monitoring is often limited, AUC-guided vancomycin monitoring may improve patient outcomes by reducing adverse effects leading to readmission or early vancomycin discontinuation.

Self Assessment Question: 
True or False: There was a significant reduction in acute kidney injury in AUC-monitored patients compared to traditional trough-based monitoring in the outpatient setting.

Eastern States Abstract
Nadine Haidar, PharmD
Preceptors: Nicholas Pugliese, PharmD, BCCCP; Olubusola Fowowe, PharmD, BCIDP; Sarah Graziose, PharmD, BCPS, BCIDP
Title
Cefpodoxime versus cefdinir for the treatment of urinary tract infections in the emergency department: a retrospective cohort study
Learning Objective
Identify differences in treatment failure between cefpodoxime and cefdinir in emergency department patients with urinary tract infections.
Background/Objective
Cefpodoxime has more favorable pharmacokinetic properties than cefdinir, yet both are used for urinary tract infections. This study evaluates differences in treatment failure between these agents in emergency department patients.
Methods
This retrospective, single-center cohort study included adult emergency (ED) patients with uncomplicated or complicated urinary tract infections (UTIs) discharged on oral cefpodoxime or cefdinir (with or without a single IV dose) and able to tolerate oral therapy. Patients were excluded if they were admitted to the hospital, had catheter-associated infections, were pregnant, had concurrent infections, or received multiple antibiotics. The primary outcome was treatment failure within 14 days, defined as return visit to a medical facility (ED, urgent care, telehealth, or outpatient clinic) for worsening urinary symptoms or antibiotic change due to persistent or worsening urinary symptoms and secondary outcomes included treatment failure at 28 and 90 days, as well as adverse drug reactions.
Results
Among 415 patients, 210 received cefpodoxime and 205 received cefdinir. Fourteen-day treatment failure was similar between groups (4.3% vs 4.4%; p=1.000), with no significant differences at 28 days (2.9% vs 3.9%; p=0.597) or 90 days (6.2% vs 10.2%; p=0.154). Cefpodoxime patients had more SIRS ≥2 (22.4% vs 14.6%; p=0.042), complicated UTI (42.9% vs 30.7%; p=0.010), and ED ceftriaxone administration (63.8% vs 52.2%; p=0.017).
Conclusion
Cefpodoxime and cefdinir demonstrated similar return-to-care outcomes after ED discharge for UTI, with no statistically significant differences in treatment failure at 14, 28, or 90 days. Despite greater baseline illness severity in the cefpodoxime group, outcomes remained comparable to cefdinir, suggesting cefpodoxime may be a reasonable oral option for ED UTI discharge. Additional studies with larger sample sizes are needed to better define its role in higher-risk UTI populations.
Self-Assessment Question
Based on the findings of this study, what conclusions can be drawn regarding cefpodoxime compared to cefdinir in ED patients with UTIs? (Select all that apply)
a) Comparable treatment failure at 14 days
b) Superior short-term efficacy of cefdinir
c) Potential differences in longer-term outcomes
d) Increased adverse drug reactions with cefpodoxime
Answer: A, C

Title: Comparing the Efficacy and Safety of Split versus Front Loading Dosing Strategies of Phenobarbital in Hospitalized Patients with Alcohol Withdrawal Syndrome
 
Authors: Jillian Johnson, PharmD; Jina Patel, PharmD, BCCCP, Peter P. Olivieri, MD, FCCP; Hyunuk Seung, MS
 
Learning Objective: At the conclusion of this presentation, the participant will be able to describe the differences in efficacy and safety outcomes between front loading and split loading dosing strategies of phenobarbital in alcohol withdrawal syndrome.
 
Background/Objective: The objective of this study is to compare efficacy and safety outcomes of front versus split loading doses of phenobarbital in patients with alcohol withdrawal syndrome to add to the limited available evidence.  

Methods: This is a retrospective chart review of patients hospitalized for the management of alcohol withdrawal syndrome (AWS) at Baltimore Washington Medical Center between May 2024-March 2026 and treated with phenobarbital. The primary objective of this study is to quantify the difference in benzodiazepine requirements during hospital stay in patients with AWS who are treated with a front or split loading dose of phenobarbital. The secondary objective is to quantify the difference in average Modified Minnesota Detoxification Scale (mMINDS) scores 24 hours after loading dose administration, length of intermediate care/intensive care unit stay, length of hospital stay, use of adjunctive agents (midazolam, dexmedetomidine, and/or propofol), and safety outcomes (need for supplemental oxygen, days requiring mechanical ventilation, occurrence of seizures). Participants were excluded if they had been admitted more than 48 hours prior to phenobarbital administration, received a midazolam infusion, propofol, or dexmedetomidine prior to phenobarbital, or were transferred from another hospital center.
 
Results: The split loading group had significantly higher total benzodiazepine requirements compared to the front loading group (44 vs 18 mg lorazepam equivalents; p=0.0017). There was no statistically significant difference in change in mMINDS scores between groups, but the front loading group had lower average 24 hour mMINDS scores post phenobarbital loading dose compared to the split loading group (4.6 vs 5.8; p=0.049). The split loading group had significantly longer ICU length of stay (3 vs 0 days; p=0.001) and hospital length of stay (5.5 vs 3 days; p=0.0048). There were no statistically significant differences adjunctive therapy requirements or safety outcomes.

Conclusions: The front loading dosing scheme of phenobarbital is associated with statistically significant lower benzodiazepine requirements, lower length of ICU stay, lower length of hospital stay, and lower 24 hour average mMINDS scores. Safety outcomes were similar among both groups. This suggests that front loading doses of phenobarbital may provide better control of symptoms of alcohol withdrawal while maintaining a similar safety profile to split loading doses.

Self-Assessment Question: True/False: Patients who received front loading doses of phenobarbital had significantly lower benzodiazepine requirements with no significant difference in ventilation duration compared to split loading doses