2026 Eastern States Conference

Title: Pharmacy-directed optimization of appropriate anaerobic antibiotic coverage
Authors: Amita Singh, PharmD; Brenden Van Slyke, PharmD; JoMarie Yazak BS
Learning Objective: Analyze the impact of pharmacist intervention and EMR-based decision support on antimicrobial stewardship outcomes, including inappropriate double anaerobic coverage use
Background/Objective:
This study aims to reduce unnecessary double anaerobic coverage by promoting de-escalation per institutional policy, thereby minimizing antibiotic overuse.
Methods:
This two-phase study will compare double anaerobic antibiotic coverage practices before and after pharmacist-led intervention. Phase one involves a retrospective chart review in the legacy system (May-September 2025) as the control, identifying all patients receiving double anaerobic coverage. Phase two is a prospective intervention period in Epic (November 2025-March 2026), where pharmacists will evaluate and de-escalate inappropriate double anaerobic coverage when clinically appropriate. Eligible patients are at least 18 years old, on double anaerobic coverage for at least 24 hours. The primary outcome is the percentage of antibiotic therapy days with guideline-inappropriate double anaerobic coverage, measured before and after intervention. Secondary outcomes include the proportion of patients on appropriate double anaerobic coverage per system guidelines and incidence of Clostridioides difficile infection.  Descriptive statistics were used to summarize outcomes, and Fisher’s Exact Test was used to compare groups, with p<0.05 considered statistically significant.

Results:
 In a single-center study, inappropriate double anaerobic coverage (DAC) decreased significantly following EPIC implementation (42.6% vs 16.1%, p=0.0119), while pharmacist interventions occurred in only two cases. Appropriate DAC use increased (40% to 81.8%) but was not statistically significant. No C. difficile infections were observed. Results suggest EMR-based decision support played a key role in improving prescribing practices.

Conclusion: 
EPIC implementation was associated with a significant reduction in inappropriate double anaerobic coverage, while pharmacist interventions were limited. Although appropriate DAC use increased, this was not statistically significant. These findings suggest that EMR-based decision support may play a key role in improving antibiotic prescribing practices, with pharmacists remaining an important component of antimicrobial stewardship efforts.

Self-Assessment Question:
Which of the following scenarios is most likely to represent inappropriate double anaerobic antibiotic coverage (DAC)?
A. Necrotizing soft tissue infection with concern for toxin production requiring clindamycin
B. Intra-abdominal infection treated with piperacillin-tazobactam and metronidazole without additional indication
C. Severe polymicrobial infection with delayed source control and hemodynamic instability
D. Empiric therapy in a patient with suspected mixed aerobic-anaerobic bacteremia pending cultures


 

Title: Evaluating the impact of pharmacist chart review intervention on the initiation of human immunodeficiency virus pre-exposure prophylaxis among high risk veterans
Authors: Allyson Sudduth, PharmD; Tanvi Patil, PharmD, BCPS, DPLA, MPH; James Martin, DO, FACOI; Christine Lanham, MSN, RN; Shikha Vasudeva, MD; Caitlin Swindall, PharmD, BCIDP
Objective: At the conclusion of my presentation, the participant will be able to describe the impact of pharmacist chart review intervention on the uptake of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP).
Self-Assessment Question: (True or false) Increasing PrEP prescriptions in high-risk patients can be fulfilled with chart intervention notes alone.
Background: Pre-exposure prophylaxis (PrEP) is highly effective at preventing human immunodeficiency virus (HIV), but is underutilized. This study aims to increase the proportion of at-risk veterans with an active PrEP prescription at a single facility.
Methods: This quality improvement study utilized the Veterans Health Administration’s national HIV PrEP dashboard to identify patients considered at risk for acquiring HIV by flagging those with a recent history of sexually transmitted infections, high risk sexual activity, or past antiretroviral prescription without a diagnosis of HIV. A pharmacist then placed a chart review note in the patients’ electronic medical records, tagging providers 1-2 weeks prior to their upcoming appointments to encourage discussion of PrEP therapy. The primary objective of this project was to describe the characteristics of patients identified by the HIV PrEP dashboard and assess the proportion of PrEP eligible patients who were initiated on PrEP therapy following pharmacist led intervention. Secondary objectives included the proportion of patients interested in PrEP following a discussion with their primary care provider and the proportion of patients initiated on PrEP following an infectious disease consult.
Results: A total of 41 patients were identified as eligible for PrEP therapy with confirmed ongoing risk of acquiring HIV. Five of the identified patients (12.2%) were men who had sex with men, thirty-six (87.8%) were flagged for high-risk sexual practices, and nine (22%) had a sexually transmitted infection in the last six months. Patients were followed for 30 days after their primary care appointment to evaluate discussion results. Ten patients have had their primary care appointment since the pharmacist intervention, and three patients (30%) have had an infectious disease consult ordered to initiate PrEP therapy. Three patients did not have a discussion of PrEP documented, three denied current sexual activity, and one declined PrEP.
Conclusion: The study results show that pharmacist chart interventions may increase PrEP utilization among high-risk patients. Ongoing interdisciplinary collaboration and communication is essential to improve HIV PrEP utilization. Providers will continue to be tagged in PrEP chart review notes on a rolling basis based on patient appointment dates to ensure timely interventions.

Title: Safety outcomes of intravenous iron therapies: low molecular weight iron dextran versus non-dextran iron products 
 
Authors:  
Adria Pirozzi, PharmD 
Kathleen Hess, PharmD, BCPS 
Christina Dickson, PharmD 
 
Learning Objective:  
Categorize the number and severity of adverse drug reactions of IV dextran versus non-dextran IV iron products.  

Self-Assessment Question:
Which of the following IV iron formulations can be administered as a single, full replacement dose?  
a. Iron sucrose
b. Ferumoxytol
c. Sodium ferric gluconate 
d. Low molecular weight iron dextran 

Background: Iron deficiency anemia is the leading cause of anemia worldwide. The primary objective is to categorize the number and severity of adverse drug reactions of intravenous (IV) low molecular weight iron dextran versus non-dextran IV iron products.  

Methods: A retrospective study was conducted among patients at the Veterans Affairs Maryland Health Care System (VAMHCS) who received intravenous iron formulations—including iron sucrose, sodium ferric gluconate, ferric carboxymaltose, Ferumoxytol, ferric pyrophosphate, or low molecular weight iron dextran—between January 1, 2024, and December 31, 2025. Patients with a documented prior allergy or adverse drug event to any intravenous iron formulation were excluded. Baseline date collected included treatment setting (inpatient or outpatient), allergy history, IV iron formulation and dose administered, and baseline iron studies. Adverse reactions were categorized according to the clinical presentation, severity, and management including medications administered, need for escalation of care, and mortality within 7 days of administration. Descriptive statistics were used to evaluate the primary and secondary study outcomes.

Results: Among 1,230 LMWID infusions, 10 reactions occurred (0.81%) with varying severity (3 mild, 3 moderate, 4 severe). Non‑dextran products had 2 reactions among 208 infusions (0.96%) of mild and moderate severity. Most LMWID reactions occurred in the inpatient setting and adults ≥ 65 years. Hypertension and congestive heart failure were the most common comorbidities among reaction cases, with fewer reactions in patients with COPD. Overall, LMWID demonstrated a low reaction rate comparable to non‑dextran formulations.

Conclusion: This study evaluates the safety of low molecular weight iron dextran (LMWID) versus non-dextran intravenous (IV) iron formulations. It will clarify the number and severity of adverse drug reactions from LMWID and assess whether age, select comorbidities, or treatment setting increase hypersensitivity risk. Results may inform clinical decisions of IV iron formulation. Results suggest LMWID has similar reaction rate to other non-dextran IV iron products.

Authors: Emma Twombly, PharmD, Christopher Devine, PharmD, BCPS, BCCCP, Jessica Marx, PharmD, BCPS 

Learning objective: Audience members will be able to explain the impact of pharmacist interventions on hyperglycemia outcomes in the hospital setting 

Background: The objective of this study is to compare the rates of hyperglycemia pre and post pharmacist insulin education. Pharmacist interventions on insulin will improve hyperglycemia rates in the hospital setting. 

Methods: This retrospective study analyzed patients admitted to a 240-bed teaching hospital. An integrative clinical pharmacy workflow tool that alerts pharmacists to potential interventions identified patients receiving insulin with at least two blood glucose readings ≥180 mg/dL. Patients ≥18 years old with at least two blood glucose readings ≥180 mg/dL were included. Patients were excluded if they were pregnant, on an insulin pump, length of stay <48 hours or who initially presented with DKA or HHS. Patient insulin regimens were reviewed for changes to assess the primary outcome of rates of hyperglycemia pre and post pharmacist education. Secondary outcomes analyzed hypoglycemic events, development of DKA, and length of stay.  

Results: 539 patients were reviewed pre pharmacist education with 14 excluded due to presenting with DKA or HHS. 491 patients were reviewed post education with 12 excluded due to presenting with DKA or HHS. 258 patients pre pharmacist education and 269 patients post pharmacist education met the inclusion criteria. The rate of hyperglycemia was 46% in the pre pharmacist education group and 55% in the post pharmacist education group (p=0.41). In the pre pharmacist education group, 17% of patients had a hypoglycemic event compared to 10% in the post pharmacist education group. No patients in either group developed DKA during their hospital stay. The average length of stay in both groups was approximately 10 days.

Conclusion: The results of this study showed clinical significance despite not being statistically significant. Despite some patients remaining hyperglycemic, when insulin regimens were adjusted in the post pharmacist education group, blood glucose readings improved. Some patients had blood glucose readings <180 mg/dL after their insulin regimen was adjusted by the pharmacist. There were fewer hypoglycemic events (blood glucose <70 mg/dL) in the post pharmacist education group suggesting insulin regimens were appropriately adjusted.
This research was supported by HCA Healthcare and reviewed by the IRB. The views expressed in this publication represent those of the authors and don’t necessarily represent the official views of HCA Healthcare or any of its affiliated entities.   

Title: Evaluating the impact of pharmacy technician-led clinics for prediabetes A1C screening to improve early detection of disease progression
Authors: Ashley Own, PharmD, Catrina Derderian, PharmD, BCACP, DPLA, Tayla Inderlin, PharmD, BCACP
Objective: Audience members will be able to identify key outcomes associated with expanding pharmacy technician-led ambulatory clinics to include annual A1C screening for patients with prediabetes.
Self-Assessment Question: Which of the following is NOT observed as a benefit of pharmacy technician-led clinics in the ambulatory care setting?
Background: This study evaluates whether expanding pharmacy technician-led clinics to include annual A1C screening improves prediabetes screening completion and early identification of diabetes progression.
Methods: This project expanded pharmacy technician-led identification, outreach, and monitoring for adults ≥18 years with prediabetes (most recent A1C 5.7-6.4%) who lacked a documented A1C in the prior 12 months across seven clinic sites. Exclusions included diabetes, pregnancy, hospice/palliative care, or an upcoming PCP visit. Technicians conducted in-person visits including medication reconciliation, blood pressure measurement, and protocol-driven ordering of A1C and lipid panels. A retrospective EMR review was used to assess outcomes from November 2025 to March 2026. The primary outcome is the number of eligible patients completing A1C screening through a pharmacy technician-led visit. Secondary outcomes include: (1) the proportion of patients with A1C ≥6.5% scheduled for PCP follow-up (2) completion of overdue lipid panels, and (3) identification of uncontrolled blood pressure with scheduling for pharmacotherapy follow-up.
Results: Among 215 scheduled patients, 147 attended their initial technician visit, of whom 144 (98%) completed A1C screening. Reasons for non-completion in 3 patients included incomplete post-visit venipuncture or an A1C already completed within the past year. All 3 patients with A1C ≥6.5% were scheduled for PCP follow-up (100%). Of 135 patients with an overdue lipid panel, 134 (99.3%) completed testing. One patient's lipid panel order was placed but remained uncompleted after their visit. Of 19 patients with blood pressure greater than 140/90, 12 (63.2%) were scheduled for pharmacotherapy services. Of the 7 unscheduled patients, reasons included existing PCP appointments, patient preference for PCP follow-up, and declination.
Conclusion: Pharmacy technician-led clinics strengthen population health efforts by improving guideline-concordant prediabetes monitoring and facilitating timely follow-up when diabetes progression is identified. Findings may inform financial impact, staffing needs, scalability to other chronic conditions, and investment in the technician career ladder to support long-term sustainability of this model.

Title: 30-Day mortality rate in patients after receiving inpatient chemotherapy and/or immunotherapy 

Authors: Donyae Brown, PharmD; Jillian Warnick, PharmD, BCPS; Monica Tong, PharmD, BCPS, BCGP; Nicole Kiehle, PharmD, BCPS; Daniel Cericola, PharmD, BCPS; Patricia Dieso, PharmD, BCPS 

Objective: At the conclusion of my presentation, the participant will be able to outline the process to determine 30-day mortality rate and complications in patients who receive inpatient chemotherapy and/or immunotherapy. 

Self-Assessment Question: What outcomes and complications should be evaluated when considering mortality rates and complications associated with inpatient chemotherapy and/or immunotherapy administration? 

Background: The purpose of this study is to identify and evaluate outcomes of patients who received inpatient chemotherapy and immunotherapy. The primary objective is to determine the 30-day mortality rate in patients after receiving inpatient treatment. 

Methods: This retrospective, descriptive study was conducted at a single center, community hospital, part of an academic health system. We identified patients who were 18 years old or older and had at least one hospital encounter with an administration of inpatient intravenous chemotherapy and/or immunotherapy for an oncologic indication from January 1, 2022, to August 5, 2025. Patients less than 18 years old or older than 88 years, pregnant or incarcerated, and patients receiving inpatient oral or non-oncologic indicated chemotherapy and/or immunotherapy were excluded. The primary outcome is the 30-day mortality rate after chemotherapy or immunotherapy inpatient administration. The secondary outcomes are median length of stay for the entire admission and after initiation of treatment, escalation of care, discharge disposition, and chemotherapy complications during admission. 

Results: Of the 141 encounters that met inclusion criteria, the median age of patients was 62 and 64.54% of patients were stage IV. For the primary outcome, the 30-day mortality rate was 15.6%. The median length of stay after initiation of chemotherapy and/or immunotherapy was 5 days, and the median length of stay for the entire admission was 9 days. Escalations in care after treatment initiation were seen in 32.62% of patients. Of all patients included in the study, 50% of all patients experienced chemotherapy complications and 34% experienced multiple. 10.64% had a suspected infection, 8.51% tumor lysis syndrome, 4.96% febrile neutropenia, 6.38% chemotherapy-induced nausea and vomiting, 14.89% anemia, and 4.96% profound neutropenia. 

Conclusion: This descriptive retrospective study is not statistically significant, but it raises important clinical questions. These include whether inpatient chemotherapy and immunotherapy affect patient outcomes, and which outcomes can we use to determine appropriateness. In the future, we plan to use this data to develop a chemotherapy stewardship program at the University of Maryland Baltimore Washington Medical Center. 

Authors 
Joanna Nguyen, PharmD; Annie Jeon, PharmD, BCPS; Lina Saliba, PharmD, BCPS, BCCCP; Jenna Smith, PharmD, BCCCP; Lois Lee, PharmD, BCPPS, BCIDP  
 
Learning objective
Describe how rapid PCR-based MRSA screening helps support antimicrobial stewardship compared to culture-based screening 
 
Background/Objective 
This study aims to compare the impact of rapid PCR-based versus culture-based MRSA screening on antibiotic stewardship outcomes, primarily vancomycin duration of therapy in hospitalized patients. 
 
Methods 
This retrospective chart review compared outcomes between culture-based (May-November 2024) and PCR-based (January-June 2025) MRSA screening following institutional implementation of the latter in December 2024. Eligible patients received at least one vancomycin dose with MRSA screening ordered within 48 hours of vancomycin initiation; patients were excluded for age under 18 years, death or transfer out of the hospital during active therapy, vancomycin for non-MRSA indications, or vancomycin therapy prior to admission. Primary outcome was vancomycin duration (reported as median with interquartile range and analyzed using Mann-Whitney U test); secondary outcomes included test turnaround time, test concordance rates, and vancomycin continuation from the Emergency Department (ED) into hospital admission. 
 
Results 
A total of 167 patients were included. Median vancomycin duration was significantly shorter in the PCR-based group compared to the culture-based group (1 vs. 3 days, p < 0.001). Turnaround time to final result was 5 vs. 29 hours from order entry and 2 vs. 26 hours from specimen collection for PCR-based and culture-based screening, respectively. The majority of test results were true negatives; false positives occurred in 13% of PCR-based and 7% of culture-based screenings. Among 40% of patients who received initial vancomycin in the ED, concurrent MRSA screening was ordered in only 59% (PCR-based) and 33% (culture-based) of these patients. Vancomycin was continued at hospital admission in up to 93% of patients. 
 
Conclusion 
PCR-based MRSA screening significantly reduced vancomycin therapy duration through rapid results and expedited de-escalation. ED screening rates remained suboptimal despite high vancomycin initiation in this population, representing an intervention opportunity. Future directions include expanding this study across the health system, optimizing timing and ordering of screening through standardized ED protocols, and educating clinical staff on PCR-based screening utility for de-escalation. 
 
Self-assessment question:  
Based on the study findings, which of the following statements regarding MRSA screening is most accurate? 
A.  PCR-based MRSA screening significantly reduced vancomycin duration of therapy compared to culture-based screening, because it demonstrated substantially higher true negative rates. 
B. PCR-based MRSA screening significantly reduced vancomycin duration of therapy compared to culture-based screening, primarily due to faster test turnaround time. 
C. PCR-based MRSA screening provided similar vancomycin duration outcomes compared to culture-based screening. 
D. PCR-based MRSA screening significantly reduced vancomycin duration of therapy compared to culture-based screening by decreasing the frequency of empiric vancomycin initiation.

Title: Phenobarbital versus Lorazepam for Treatment of Alcohol Withdrawal Syndrome in the Intensive Care Unit
Authors: Sara Clarke, PharmD; Amy Cook, PharmD, BCPS
Background: Alcohol Withdrawal Syndrome (AWS) is a life-threatening medical condition that can present with a range of symptoms including mild agitation, nausea, seizures, hallucinations, coma, and even death. Patients with AWS often experience suboptimal outcomes due to inconsistent management and lack of evidence-based care provided across care settings. First-line treatment for AWS is symptom-triggered benzodiazepines based on Clinical Instrument Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scores and phenobarbital is considered a second-line treatment option.
Objective: The primary objective of this study was to evaluate the difference in phenobarbital and lorazepam on intensive care unit (ICU) length of stay when utilized for alcohol withdrawal treatment. Secondary objectives include hospital length of stay, time on mechanical ventilation, dexmedetomidine use, midazolam use, propofol use, and CIWA-Ar scores in ICU / trauma patients.
Methods: This was a retrospective, observational, cohort study that reviewed electronic health records at a single-center,340-bed community hospital in Richmond, Virginia with 24 ICU beds from January 1, 2025 through July 10, 2025. Patients were included if they were 18 years or older, had a diagnosis of alcohol use disorder with concerns for alcohol withdrawal syndrome, admitted to the ICU, and had orders for phenobarbital or lorazepam. Patients were excluded if they were pregnant or CIWA-Ar scores were not documented. Baseline characteristics were collected for age, sex, race/ethnicity, and comorbidities. CIWA-Ar scores, length of stay (ICU and hospital), ventilator days, dexmedetomidine use, midazolam use, propofol use, and sedation scores were also collected. 
Results: Research in progress.
Conclusion: Research in progress.

Authors
Clarissa Santori, PharmD; Benjamin Miller, PharmD 
 
Learning Objective  
Audience members will be able to describe how rapid molecular blood culture diagnostics influence the timing of targeted antimicrobial therapy in patients with positive blood cultures at a community hospital 
 
Background/Objective
Bloodstream infections are among the most common and serious infections among hospitalized patients. While early appropriate antimicrobial therapy is crucial to survival, this should be balanced with good antimicrobial stewardship to minimize unnecessary broad-spectrum therapy.
 
Methods 
This was a retrospective, quasi-experimental pre–post cohort study conducted at a community hospital. The study compared outcomes before and after implementation of the BioFire BCID2 panel.  
The intervention consisted of utilizing BCID2 on all blood cultures with a positive gram stain, implemented with provider education regarding result interpretation. Adult patients (≥18 years) with at least one positive blood culture during the study period were eligible. Patients who died or were transitioned to hospice within 72 hours of blood culture collection were excluded, as were those who were discharged within 48 hours.
The primary outcome was time from blood culture collection to targeted antimicrobial therapy, defined as the first antimicrobial regimen consistent with organism identification and susceptibility results. Secondary outcomes included total antimicrobial days of therapy, broad-spectrum antimicrobial days of therapy, hospital length of stay, and included incidence of C. difficile infection. 
 
Results
TBD 
 
Conclusions
TBD 

Title: Evaluation of proton pump inhibitors on discharge list without a documented indication at a community hospital

Authors: Brooke Wagner, PharmD; Kevin Dilley, PharmD; Matthew Montavon, PharmD

Objective: Identify clinician-centered barriers to de-prescribing proton pump inhibitors (PPIs) at hospital discharge.

Self-assessment Question: True or False: A patient who was taking a proton pump inhibitor prior to admission should automatically be continued on the same therapy at discharge.

Background: To evaluate the incidence of PPIs at hospital discharge without an appropriate indication.

Methods: This single-center retrospective medication use evaluation included adults 18 years and older who were discharged on a proton pump inhibitor (PPI) from Southern Ohio Medical Center over a one-month period (February 1, 2026 through February 28, 2026) identified through manual chart review of electronic health record reports to assess the appropriateness of the documented indication. The primary outcome was the proportion of patients discharged on a PPI without a documented indication, defined by established criteria; secondary outcomes included duration of therapy and inpatient initiation. Descriptive statistics were used for analysis.

Results: A total of 404 encounters were reviewed during the study period. Of these, 399 patients (98.8%) were discharged on a PPI and included in the primary analysis. 5 patients (1.2%) were not discharged on a PPI. Among the 399 patients discharged on a PPI, 339 (85%) had an appropriately documented indication. The primary outcome showed that 60 patients (15%) were discharged on a PPI without an appropriate documented indication. The appropriate duration of therapy was documented in 27 of 399 patients (6.8%). The remaining 372 patients (93.2%) had an inappropriate or unclear discharge therapy duration. PPI therapy was newly initiated during hospitalization in 4 of 399 patients (1%). Most patients discharged on a PPI were continued on therapy present before admission, accounting for 395 of 399 (99%). The most common PPI agents prescribed at discharge were pantoprazole and omeprazole. Pantoprazole accounted for 220 of 399 PPI discharges (55.1%), and omeprazole accounted for 131 of 399 discharged patients (32.8%).

Conclusions: In this medication use evaluation, 15% of patients discharged on a PPI did not have an appropriate documented indication. Only 1% of patients were newly initiated on PPI therapy during hospitalization and continued after discharge, indicating that most discharge PPI prescribing reflected continuation of pre-admission therapy. These findings suggest that pharmacist-led discharge stewardship should focus on reassessing chronic outpatient PPI therapy, clarifying the indication, and documenting the intended duration when continued therapy is appropriate.

Authors: Bryn Damico, PharmD; Evan Hurley, PharmD, BCIDP
Learning Objective: Describe the role of a pharmacist in outpatient intravenous antibiotic order review prior to discharge at a community hospital 
Background/Objective: Evaluate a pharmacist review of outpatient intravenous antibiotic orders at discharge on readmission outcomes.   
Methods: This is a single-center retrospective cohort study examining a pharmacist-led review of patients discharged with outpatient intravenous antibiotics in a community hospital. Inclusion criteria include patients with an order for outpatient intravenous antibiotics placed by an infectious disease provider within 10 days of discharge.  Exclusion criteria include patients less than 18 years of age, plans to discharge to a rehabilitation center, or patients who were transferred to an outside hospital. The pre-implementation phase consisted of a chart review of patients with orders for outpatient intravenous antibiotics between January 2025 to June 2025. In the post- implementation phase, pharmacists reviewed outpatient intravenous antibiotic orders once daily, then recommended antibiotic change based on predefined workflow. The primary outcome was infection-related hospital readmission within 30 days of discharge. Secondary outcomes included all-cause readmissions, emergency department visits, all-cause mortality, and adverse events within 30 and 90 days. This quality improvement project does not require Institutional Review Board (IRB) approval. 
Results: There were 33 patients included in the post-implementation cohort. Pharmacists identified interventions in 9 of 33 patients (27%), including antimicrobial selection changes, dose adjustments, and duration changes, of which 5 (56%) were accepted. The primary outcome of infection-related hospital readmission within 30 days occurred in 9% of patients. All-cause readmission at 30 days occurred in 24% of patients and infection-related emergency department visits in 21%. At 90 days, evidence of treatment failure occurred in 9% of patients, adverse events in 12%, and no mortality was observed.
Conclusion: There are opportunities to optimize transitions of care when treating patients with outpatient intravenous antibiotics including dose, route, duration, and antimicrobial selection. Implementation of a pharmacist-led review of OPAT orders prior to discharge is feasible at a community hospital, with pharmacists identifying optimization opportunities in 27% of patients. Evidence of 90-day treatment failure was reduced from 16% pre-implementation to 9% post-implementation, suggesting possible downstream clinical benefit of pharmacist optimization.
Self-Assessment Question: Which of the following ways can pharmacists contribute to reviewing outpatient intravenous antibiotic therapy prior to discharge?

Title:
Improving SGLT2 inhibitor prescribing at discharge in patients with HFrEF

Authors:
Lotanna Ezeofor, PharmD; Stephie Ikama, PharmD Candidate; Pavel Goriacko, PharmD, MPH; Angela Cheng, PharmD, BCPS, FASHP

Objective:
To increase the rate of SGLT2 inhibitor prescriptions at hospital discharge to ≥70% among eligible patients with heart failure with reduced ejection fraction.

Self Assessment Question:
Which intervention is most effective in improving SGLT2 inhibitor prescribing at discharge for eligible patients with HFrEF?

Background:
Sodium-glucose cotransporter 2 inhibitors are guideline-directed medical therapy for HFrEF and have demonstrated reductions in mortality and heart failure hospitalizations. Despite increased inpatient initiation following formulary addition and electronic order set implementation, discharge prescribing remains suboptimal, highlighting a gap in transitions of care.

Methods:
This performance improvement project will use a Plan-Do-Study-Act framework at a large academic medical center. A retrospective chart review will identify eligible HFrEF patients and evaluate baseline discharge prescribing rates and barriers. Targeted interventions, including electronic medical record enhancements, provider education, and workflow modifications, will be implemented and assessed for their impact on prescribing rates.

Results:
Data collection and analysis are ongoing. We anticipate identifying key barriers to discharge prescribing and expect that implementation of targeted interventions will improve prescribing rates toward the institutional goal. Final results will be presented.

Conclusion:
This initiative aims to improve adherence to guideline-directed medical therapy at discharge and strengthen transitions of care. Findings may support scalable strategies to optimize SGLT2 inhibitor prescribing and improve outcomes in patients with HFrEF.

Title: Optimizing Peri-Operative Management of SGLT-2 Inhibitors
Authors: Michele Mathew, PharmD; Jennifer Premus, PharmD; Elaena Quattrocchi, BS, PharmD, FASHP, CDC; Preethi Samuel, PharmD, BCACP, AAHIVP 
Self Assessment Question:
Which of the following best describes the recommended peri-operative management of SGLT-2i to reduce the risk of EDKA?
A. Continue therapy until the morning of surgery
B. Hold the medication 24 hours before surgery
C. Hold the medication at least 72 hours prior to surgery or procedures requiring anesthesia
D. Discontinue therapy only after surgery is completed
Learning Objectives:  
At the conclusion of this presentation, participants will be able to: 
Explain how SGLT-2i contribute to EDKA development in surgical patients
Describe the mechanism of EDKA associated with SGLT-2i use in the peri-operative setting
Evaluate the adherence to institutional SGLT-2i management guidelines
 
Background/Objective: SGLT-2i improve cardiovascular and renal outcomes but their use has been linked to an increased risk of EDKA. Generally, SGLT-2i are held for at least 72 hours prior to surgery or procedure. Currently, there are limited studies evaluating SGLT-2i use in the preoperative setting. By addressing this gap in the literature, the study aims to clarify whether adherence to institutional policies can reduce the rate of EDKA and improve preoperative safety for patients taking SGLT-2i. 
 
Methods: This is a single-center retrospective chart review evaluating adherence to institutional preoperative SGLT-2i protocols and the incidence of EDKA in surgical patients at Staten Island University Hospital. Subjects for inclusion were identified from the electronic medical record as adult patients >18 years who had a procedure or surgery requiring anesthesia between February 22, 2024 - October 1, 2025. Eligible patients must have been prescribed a SGLT-2i prior to surgery or procedure. Exclusion criteria include patients <18 years and pregnancy. The primary outcome will be the percentage of patient's adherent to SGLT-2i institutional preoperative management guidelines. Secondary outcomes will include incidence of EDKA in adherent versus non-adherent patients, patient or surgery-related risk factors associated with EDKA, and clinical outcomes such as hospital length of stay and in-hospital mortality.

Results: Among 517 patients evaluated, only 212 patients (41%) appropriately adhered to Northwell Health’s peri-operative SGLT-2 inhibitor management policy. Policy non-adherence occurred in 305 patients (59%), with the primary reason being unknown SGLT-2 inhibitor hold duration in 288 patients (94.4%), followed by inappropriate medication hold in 17 patients (5.6%). Missing EDKA diagnostic laboratory values were present in 266 patients (87.2%). Mean SGLT-2 inhibitor hold duration was 4.12 ± 1.4 days. No confirmed cases of EDKA were identified in either the appropriately held or non-adherent groups, median hospital length of stay was 2 days (IQR 1–5), and mortality was low at 0.2% (1 patient).

Conclusion: The primary barriers to compliance were largely related to documentation deficiencies, incomplete medication reconciliation, and unclear preoperative hold durations rather than deliberate inappropriate prescribing. Although no confirmed cases of EDKA were identified, the high frequency of missing diagnostic laboratory values likely limited accurate event detection and may underestimate complete incidence. These findings suggest that while institutional guidelines provide an important for reducing perioperative EDKA risk, policy implementation alone is insufficient without effective interdisciplinary education and consistent provider awareness,

Title:
Assessing the impact of a pharmacist-led proton pump inhibitor deprescribing initiative on the pattern of proton pump inhibitor use.

Authors:
Min Jung Jo, PharmD; Kelsey Ryan, PharmD

Objective: 
Audience members will be able to describe the impact of a pharmacist-led proton pump inhibitor (PPI) deprescribing initiative on the pattern of PPI use.

Self-Assessment Question: 
How can pharmacists promote appropriate use of PPIs in hospital settings?

Background: 
While proton pump inhibitors (PPIs) can effectively treat acid-related gastrointestinal disorders, overuse during hospital admissions is an ongoing concern. Pharmacist-led interventions can reinforce appropriate use of PPIs.

Methods: 
This pre- and post-implementation study evaluated the pattern of proton pump inhibitor (PPI) use in two publicly funded hospitals and assessed the impact of a pharmacist-led PPI deprescribing initiative after a proposed intervention. Pre-intervention data came from patients with an active PPI order between September 2024 and August 2025. Patients who were hospitalized for less than 3 months or already discharged were excluded. Data collected included treatment duration, indication, deprescribing attempts, and reported adverse effects associated with long-term use. The intervention included an in-service presentation focused on PPI deprescribing and an evidence-based deprescribing algorithm for providers to reference. Post-intervention data included PPI orders discontinued, dose or frequency adjustments, or change to a different antisecretory agent.

Results: 
Prior to intervention, 98 patients were identified for data analysis. Thirty-seven (37.8%) had an appropriate indication for long-term PPI use. There were 91 (92.9%) patients who were prescribed a PPI for more than 3 months. PPI use beyond 1 year was seen in 43 (43.9%) patients, half of which experienced hypomagnesemia, hypocalcemia, or C. difficile related diarrhea. Deprescribing attempts were documented in 32 (23.5%) patients. Post-implementation preliminary data includes 86 patients. PPI deprescribing attempts were made in 21 (24.4%) patients. Data collection is ongoing; results may be updated.

Conclusion: 
Findings from this study suggest that pharmacist-led interventions may reinforce more safe and effective use of PPIs.

Authors: Seo Young Chun, PharmD; Melissa Chaung, PharmD, BCPS; Michael A. Wynd, PharmD, BCPS

Learning Objective: At the conclusion of my presentation, the audience will be able to compare the allograft function outcomes of early vs late conversion from tacrolimus to belatacept in kidney transplant recipients. 

Background/Objective:
Assess the impact of timing of conversion from tacrolimus to belatacept on allograft function in kidney transplant recipients (KTRs).

Methods:
This was a single-center, retrospective cohort study evaluating first kidney-alone, adult (age ≥ 18 years at the time of conversion), Epstein-Barr virus IgG seropositive KTRs who converted from tacrolimus to belatacept between January 1, 2013, and December 31, 2024. Recipients of multi-organ transplants or patients receiving belatacept for < 30 days were excluded. Outcomes at 1-year post-conversion were compared between KTRs who converted early (< 6 months post-transplant) vs late (≥ 6 months post-transplant). The primary endpoint was the change in estimated glomerular filtration rate from baseline. Secondary endpoints included patient and allograft survival, biopsy-proven acute rejection, opportunistic viral infections, malignancy, discontinuation-rate of belatacept, and adverse events. Demographic data, within-cohort, and between-cohort comparisons were analyzed using appropriate statistics.

Results:
Of 177 patients screened, 76 patients were included, with 67 patients in the early conversion group and 9 patients in the late conversion group. Baseline demographics were similar between groups, although pre-transplant donor-specific antibodies were more common in the late conversion group (44.4% vs 11.9% [p = 0.04]). Median eGFR at conversion was lower in the early conversion group compared to the late conversion group (20 vs 45 mL/min/1.73m2 [p = 0.01]). At 1 year post-conversion, the early conversion group demonstrated a greater change in eGFR (23 vs 7 mL/min/1.73m2 [p = 0.0083]). No significant differences were observed in patient and allograft survival, rejection, opportunistic infections, and belatacept discontinuation between groups. 

Conclusion:
Early conversion from tacrolimus to belatacept was associated with greater improvement in eGFR, likely reflecting lower baseline eGFR and greater opportunity for recovery at the time of conversion. While interpretation is limited by the disproportionately smaller late conversion cohort, this study provides descriptive real-world data on institutional belatacept conversion practices and outcomes across different conversion strategies.

Self-Assessment Questions:
Which of the following is a common reason for patients to convert from tacrolimus to belatacept?

1. Nephrotoxicity
2. Gastrointestinal side effects
3. Neurotoxicity
4. All of the above

Title: Incorporating penicillin allergy assessment in preoperative evaluation: landmine antimicrobial stewardship effort in support of surgical services within a military treatment facility

Authors: Kailey B. Moss, PharmD; Memar D. Ayalew, PharmD, BCIDP, AAHIVP

Learning Objective: Describe the impact pharmacist-led penicillin de-labeling services can have on optimizing surgical prophylaxis.

Background/Objective: Identify patients with penicillin and/or other β-lactam allergies ahead of elective surgical procedures, provide a link to appropriate de-labeling services in the perioperative arena, and facilitate access to first-line prophylactic antibiotics.

Methods: Utilizing generated reports, pharmacist-led Penicillin Allergy Management (PAM) clinic personnel screened and identified the target population: patients > 18 years of age, non-pregnant, labeled penicillin (PCN) and/or other β-lactam allergy, and anticipated procedure between Oct. 1st to Dec. 31st, 2025.
An Antimicrobial Stewardship Pharmacist then risk-stratified patients with labeled PCN allergies using previously validated risk assessment tools (PEN-FAST and PAT-C score), with low-risk patients contacted to schedule a direct oral amoxicillin challenge (DOAC) appointment prior to respective surgery.
Patients identified as having moderate to high risk PCN and/or cephalosporin allergies were referred to the Allergy and Immunology (A/I) clinic for further evaluation by an allergist.
Upon successful intervention either by PAM or the A/I clinic, the allergy was removed from the health record, and the patient was longitudinally followed for utilization of first-line prophylactic antibiotics.

Results: A total of 962 patients were screened over the course of the 3-month period with 99 (10%) patients flagged as having a PCN and/or other β-lactam allergy, 93-99% of whom were stratified as having low-risk PCN allergy. Twenty patients in this cohort were de-labeled successfully either by DOAC or chart review: 14 were de-labeled prior and 6 were de-labeled after their respective procedure. Of the 14 patients de-labeled prior to surgery, 10/14 required administration of systemic antibiotics with 8/10 (80%) receiving first-line surgical prophylaxis. This compares to only 15/38 (39%) patients who received first-line surgical prophylaxis in individuals unable to receive intervention prior to procedure (p-value < 0.05).

Conclusion: Consistent with reported literature, we found local prevalence of patients with PCN and/or other β-lactam allergy in this study cohort to be 10%. Following successful pharmacist-driven de-labeling, 80% of patients received first-line prophylactic antibiotics. This demonstrates that appropriate de-labeling in the perioperative arena is essential to optimizing surgical prophylaxis, and by extension, critical to improving overall patient outcomes.

Self-Assessment Question: Which tool(s) can be utilized to determine risk of an IgE-mediated reaction to a direct oral amoxicillin challenge in patients with a penicillin allergy?
A. PEN-FAST Score
B. PAT-C Score
C. q-SOFA Score
D. MELD Score
E. Both A and B

Risk Factors for Surgical Site Infections in Orthopedic Surgery: A Case-Control Study 
Lama Almutairi, Michael Klompas, James Maguire, Madeleine Bartzak, Brandon Dionne, Jeffrey C. Pearson

Background/objective:
Surgical site infections (SSIs) complicate orthopedic surgery, highlighting the need to clarify associated risk factors. By the end of the presentation, participants should be able to identify risk factors for SSIs in hip or knee surgery.

Methods:
This was a single-center retrospective case-control study conducted at a tertiary academic medical center. Patients who underwent orthopedic knee or hip surgery between August 2020 and May 2025 were included. Cases were patients who developed an SSI within 90 days, according to the National Healthcare Safety Network criteria. Controls were patients who did not develop an SSI within the same follow-up period. Cases were matched 1:4 to controls by surgery type (hip vs. knee) and procedure date (month and year). The association between risk factors and SSIs was assessed using univariable and multivariable logistic regression. Prespecified risk factors included body mass index (BMI) ≥25 kg/m², diabetes mellitus with most recent A1C ≥7%, surgical duration ≥120 minutes, age ≥60 years, S. aureus nares screening, and perioperative antibiotic choice (cefazolin alone vs. other).

Results: 
Among 250 patients (50 cases, 200 controls), the mean BMI was 30.2 kg/m² for cases and 27.9 kg/m² for controls. Hypertension was present in 62% of cases versus 55% of controls, and diabetes was present in 24% of cases versus 14.5% of controls. Perioperative antibiotic regimens were similar between groups: cefazolin alone was used in 48% of cases vs 49% of controls, while cefazolin plus vancomycin was used in 40.0% vs 43.5%. S. aureus was the most common pathogen. Of the prespecified risk factors, BMI ≥25 kg/m² [adjusted odds ratio (aOR) 3.59, 95% confidence interval (CI) 1.21-10.66] and surgical duration ≥120 minutes [aOR 2.30, 95% (CI) 1.18-4.48] were each associated with an increased risk of SSIs in the multivariable regression analysis.

Conclusion:
These findings provide insight into risk factors associated with SSIs, which can be considered to optimize peri-operative practices to reduce SSIs risk in patients undergoing orthopedic surgery.

Assessment Question
Which of the following perioperative risk factors has been associated with an increased risk of surgical site infection following orthopedic surgery?

1. Age younger than 50 years

1. Surgical duration ≤60 minutes

1. Body mass index ≥25 kg/m²
2. Cefazolin alone for surgical prophylaxis

Correct answer: C

Authors: Simran Kaur, PharmD; Jeffrey Hare, PharmD; Brianna Schafer, PharmD, BCPPS; Sewit Araia, PharmD 
Objective: At the conclusion of this presentation, the participant will be able to describe the incidence of severe adverse effects associated with intravenous iron dextran compared with iron sucrose in pregnancy
Pre-assessment question: Which IV iron formulation is associated with a higher risk of severe AE in pregnancy? (A. Iron sucrose B. Iron dextran C. Both have similar risk D. Not sure) 
Background: Intravenous iron is used when oral therapy is inadequate; however, comparative safety data among formulations are limited. This study compares the incidence of severe adverse effects between iron dextran and iron sucrose in pregnant women. 
Methods: This retrospective cohort study included pregnant women of any gestational age who received intravenous iron dextran or iron sucrose within the Geisinger Health System during the iron sucrose shortage from March 25, 2024, to February 20, 2025. Patients were identified using electronic health record medication and diagnosis codes. The primary outcome was the incidence of severe adverse effects, including anaphylaxis, circulatory failure, shock, etc. occurring within 24 hours of iron administration. Secondary outcomes included pre-treatment medications, emergency department admission, hospital admission, and administration of rescue medications. Adverse effects were categorized using Common Terminology Criteria for Adverse Events grading. Primary and secondary outcome incidence rates were compared using fisher’s exact test. 
Results: Data from 150 patients per group were analyzed. Median age was 27 years, with gestational age 33 weeks (iron dextran) and 32 weeks (iron sucrose). Inpatient administration was less frequent with iron dextran (1.33%) vs iron sucrose (9.33%). Adverse events occurred in 2.7% of iron dextran patients and 0% with iron sucrose (p=0.1225). In the dextran group, 38% received premedication, with one ED visit (p=1), no hospitalizations, and 4 patients requiring rescue medications (p=0.1225).
Conclusion: In conclusion, Iron sucrose had zero incidence of adverse events, and they were more often observed in the patients that received iron dextran, however severe adverse events were uncommon. Iron dextran can be considered a safe alternative treatment for iron deficiency anemia in pregnancy when iron sucrose is not readily available as the preferred agent

LEARNING OBJECTIVE: 

1. Learners will be able to recognize opportunities to improve antibiotic prescribing for SSTIs in a community hospital emergency department

BACKGROUND/OBJECTIVE:  This study aims to characterize and evaluate the appropriateness of antibiotic prescribing for skin and soft tissue infections (SSTI) in patients who are discharged from either Cambridge Health Alliance emergency departments (ED).

METHODS: A retrospective chart review will evaluate adult patients (≥18 years of age) discharged from our institution’s emergency departments with a primary chief complaint of cellulitis or abscess. Exclusion criteria include inpatient admission, concomitant or deep tissue infections, bone and joint infections, infections of the mouth, head, neck, or foot, those involving a bite, surgical site, or underlying hardware, or re-presenting within 72 hours of the index admission for the same infection. Treatment data collected includes incision and drainage and antibiotic agent, dose, and duration. Patients will be categorized by wound purulence and IDSA-defined infection severity (mild, moderate, severe). The primary outcome will be adherence of antibiotic agent, dose, and duration prescribing to 2014 IDSA guidelines. Secondary outcomes include readmission within 30 days of the index ED encounter and documented adverse reaction to antimicrobial therapy. 

RESULTS: 200 patients were included in the analysis. Appropriateness was defined as being in compliance with IDSA 2014 guidelines in respect to antibiotic agent, dose, and duration. 32.1% of purulent and 18.8% of nonpurulent infections were prescribed antibiotic regimens in compliance with guideline recommendations. Of these, 56.5% and 71.9% of purulent and nonpurulent infection antibiotics, respectively, were deemed inappropriate due to the duration of therapy. Antibiotic therapy was inappropriate due to broadened coverage in 26.2% and 56.3% of purulent and nonpurulent infections, respectively. In 3.5% and 6.3% of antibiotic regimens, the prescribed dose was below recommended ranges. All cause 30-day readmission was 16.1% and 25% with two documented adverse reactions.

CONCLUSION: It is anticipated that this quality improvement project will provide insight into prescribing practices for SSTIs at our institution’s EDs and opportunities for improvement. Based on these results, the authors plan to propose interventions to the ED which may include additional clinical decision-making support and/or providing departmental education.

SELF ASSESSMENT QUESTION: Which of the following findings is the most appropriate target for an antimicrobial stewardship intervention in adult patients discharged from the ED with SSTIs at our institution?

Authors: Lexi Barbush, PharmD; Sheshadri Hoque, PharmD; Evan Hurley, PharmD, BCIDP 
Learning Objective: Identify common medication errors at discharge in patients initially admitted with sepsis to implement effective pharmacist-led review processes 
Self-Assessment Question:  
True/False Pharmacist intervention led to a decrease in medication errors attributable to readmissions after being hospitalized for sepsis
Background/Objective: Sepsis hospitalizations often require reassessment of chronic medications due to changes in clinical baseline, yet optimization at discharge may be overlooked as focus remains on the acute infection. 
Methods: This was a pre- and post-implementation study that was conducted September 2025 through March 2026. This study included patients ≥18 years old who were hospitalized with sepsis. Patients were excluded if they were discharged to hospice, or left against medical advice. A pharmacist assessed antihypertensives, antimicrobials, antidiabetics, and anticoagulants. Types of interventions involved dose adjustments, discontinuation of duplicate or unindicated therapies, identification of discharge list discrepancies, and initiation of indicated therapies. The primary outcome was 30-day readmissions in patients with reviewed discharge lists versus unreviewed discharge lists. Secondary outcomes included types of interventions and the number of accepted vs rejected interventions. 
Results: Preliminary results for January through February 2026 show that the readmission rate in unreviewed patients is 21% vs 13% in the reviewed patient group (p=0.2). The most common intervention type was adding a medication at discharge and most interventions were concerning antihypertensives. The most frequently rejected intervention was removing an antimicrobial from the discharge list, as providers preferred to extend therapy past IDSA guidelines recommended durations. Most notably, of the reviewed patients who were readmitted (n=11), zero were due to reasons relating to the pre-defined drug classes and the disease states they manage versus 9 of the 50 readmitted patients in the pre-implementation group.
Conclusion: Preliminary data demonstrates that in patients initially admitted with sepsis, the pharmacist-reviewed group had a lower readmission rate compared to non-reviewed patients (13% vs 21%, p=0.2). The pharmacist-review process led to a decrease in readmissions attributable to errors in the pre-defined drug classes or the disease states they target compared to Phase I readmitted patients (0% vs 18%).

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: Systemic corticosteroids with or without stress ulcer prophylaxis: a retrospective comparative analysis of gastrointestinal bleeding risk and adverse outcomes

Authors: Sara Girgis, PharmD; Shivankar Vajinepalli, PharmD; Megan Trombi, PharmD; Yong-Bum Song, PharmD

Objective: The audience will be able to compare the risk of stress-related gastrointestinal bleeding (GIB) in hospitalized patients receiving systemic corticosteroids (SCS) with and without stress ulcer prophylaxis (SUP).

Self-Assessment Question: True/false: The 2024 Society of Critical Care Medicine (SCCM) Guideline for the Prevention of Stress-Related GIB in Critically Ill Adults considers SCS a risk factor for stress-related GIB that necessitates SUP. 

Background: Evidence correlating SCS and GIB is limited, and current guidelines do not recommend SUP for patients receiving SCS. This study aimed to evaluate whether coadministration of SUP is associated with a lower incidence of GIB in patients receiving SCS.

Methods: This single-center, retrospective chart review included patients aged 18 years or older who received SCS for at least 24 hours, with or without coadministration of SUP such as pantoprazole or famotidine. Patients with active GIB upon admission or with risk factors for GIB who required SUP, were excluded. The primary outcome compared the incidence of clinically important GIB between the cohorts. The secondary outcomes assessed the occurrence of adverse effects associated with SUP, including newly confirmed pneumonia, Clostridium difficile, and change in platelet count. 

Results: The analysis included 412 patients, of whom 176 received SCS along with SUP and 236 received SCS alone. Among those patients, clinically significant GIB was observed in one patient (0.4%) from the SCS-alone group (p > 0.99). Newly confirmed pneumonia developed in 14 patients overall, consisting of 4 patients (3.4%) in the SCS + SUP group and 10 patients (4.2%) in the SCS-alone group (p = 0.28). There were no reported cases of Clostridium difficile in either cohort. The median change in platelet count for the SCS + SUP group was -15, whereas the SCS-alone group was -13 (p = 0.31).


Conclusions: The use of SUP was not associated with a lower incidence of clinically significant GIB among patients receiving SCS. The incidence of newly confirmed pneumonia, Clostridium difficile infection, and change in platelet count were not significantly different between the cohorts. Future research involving larger sample sizes is essential to further assess whether SUP is associated with a lower incidence of clinically significant GIB in this patient population.

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.

Title: Cost-effectiveness of paliperidone long-acting injectable antipsychotic vs oral second-generation antipsychotics in patients hospitalized for psychosis

Authors: Baylee Beaver, PharmD, MBA; Michaela E. Huddleston, PharmD, BCPS, BCGP, BCPP; Lora Good, PharmD; Patrick Kerr, PhD; Jonathan Robles-Diaz, PharmD; Brian Burton, MS

Background: This study evaluates the true cost-effectiveness of paliperidone long-acting injectable (LAI) in patients with schizophrenia and schizoaffective disorder to guide clinical practice and administrative decisions regarding antipsychotic selection.  

Methods: Medical records of 200 patients admitted to the inpatient psychiatric unit at CAMC General Hospital for schizophrenia or schizoaffective disorder from September 1st, 2016, to September 1st, 2024, were reviewed. Data collected included patient demographics, prescribed second-generation antipsychotic information, hospital length of stay (LOS) and cost, number of emergency department (ED) visits and hospital inpatient admissions in the 12-months before and after the index admission, and social determinants of health.

Results: The mean admission cost of patients discharged paliperidone LAIs was lower compared to patients discharged on oral second-generation antipsychotic agents ($76,964.40 vs $43,049.80, p<0.0001). Patients started on paliperidone LAI had longer LOS on the index admission compared to patients on oral second-generation antipsychotics (10.98 days vs 8.69 days, P=0.0001). No difference was identified in the number of readmissions or ED visits between groups. Among patients who were readmitted, there was no difference in LOS between the two groups. 

Conclusions: Paliperidone LAIs were associated with lower admission costs despite the association with a longer length of stay. However, there was no improvement in the rate of readmissions and emergency department visits.

Title: Real-world assessment of rapid blood culture identification technology on emergency department blood culture callback process 
Authors: Eleanor Carr, PharmD, Casey Boyer, PharmD, BCEMP, Sangeeta Sastry, MD, Jihye Kim, PharmD, BCPS, BCIDP 
Learning Objective: Describe the clinical impact of BioFire® FilmArray® Blood Culture Identification 2 (BCID2) implementation on readmission rate for patients with coagulase-negative Staphylococcus (CoNS) -positive blood cultures after discharge from the emergency department (ED).  
 
Self-Assessment Question: 
What outcome significantly changed after implementation of BCID2 for patients who returned to the ED with coagulase‑negative Staphylococcus–positive blood cultures? 

1. Readmission rate 
2. Hospital length of stay  
3. Prolonged antibiotic administration
4.  None

Background:  
The objective of the study is to compare the callback readmission rates in patients discharged from the ED with CoNS blood cultures prior to and after BCID2 implementation at our institution on March 13,2023. 
 
Methods: 
This is a single‑center, retrospective, pre-post quasi-experimental study of adult patients (≥18 years) with at least one positive blood culture for CoNS and discharged from the ED between January 1, 2022, and August 31, 2025. Patients with polymicrobial blood cultures were excluded. Outcomes included hospital readmission rates, empiric CoNS antibiotic initiation upon readmission, and antibiotic duration greater than 72 hours, with statistical analyses performed using JMP® software. 
  
Results:  
A total of 55 patients (pre-BCID2, n=31; post-BCID2, n=24) met inclusion criteria. Readmission rate after BCID2 implementation was not statistically different between the two groups (pre-BCID2: n=18/32 (58.1%) vs post-BCID2: n=12/24 (50%), p = 0.5945). Implementation of BCID2 was associated with a significant decrease in antibiotic initiation upon readmission (pre-BCID2: n=14/18, (77.8%) vs post-BCID2: n=4/12 (33.3%), p = 0.0243). Additionally, prolonged use of empiric antimicrobials was significantly higher in pre-BCID2 group compared to post-BCID2 group during further evaluation upon readmission (pre-BCID2: n=5/18 (27.8%) vs post-BCID2: n=0/12 (0%), p = 0.0455).  
  
Conclusion: 
The implementation of BCID2 did not significantly reduce readmission rates among patients with CoNS‑positive blood cultures at our institution. However, BCID2 was associated with a statistically significant reduction in rates of antibiotic initiation and prolonged duration of therapy. These findings highlight an opportunity to further characterize re-admitted patients and develop an institution‑specific protocol to optimize and standardize ED blood culture callback processes and resource utilization. 
 

Title: Comparing the effectiveness of glucagon-like peptide 1 receptor agonists and sodium glucose co-transporter 2 inhibitors in a nationwide observational cohort study on the rates of cardiovascular outcomes.
Authors: Madison Jones, PharmD; Tanvi Patil, PharmD, BCPS, DPLA; John Minchak, PharmD, MBA, BCPS, BCGP; Alamdeep Kaur, PharmD, BCPS
Learning Objective: At the conclusion of my presentation, the participant will be able to explain the comparative effectiveness of glucagon-like peptide 1 receptor agonists (GLP1-RA) versus sodium glucose co-transporter 2 inhibitors (SGLT2i) on cardiovascular outcomes in a nationwide observational cohort study.
Background/Objective: The purpose of this study is to compare cardiovascular composite outcomes in patients newly initiation on GLP1-RA or SGLT2i.
Methods: This retrospective active comparator new-user cohort study included veteran patients who newly initiated on either GLP1-RA or SGLT2i. We collected electronic health record data from nationwide Veterans Health Administration (VHA) database from 1/1/2018 through 1/1/2024.   Data was collected and combined from individual electronic medical records to the VA Corporate Data Warehouse (CDW) where it was modeled and prepared for use by The VA Informatics and Computing Infrastructure (VINCI) and extracted for study using sequel query language. We included patients who were newly started on either an SGLT2i or GLP1-RA. Patients taking a combination of a GLP1-RA and an SGLT2i any time before, during, or after the study period were excluded.  Patients with type I diabetes, renal or liver transplants prior to or during the duration of the study were excluded. Patients were excluded if they did not have any encounters with VA healthcare system within the past 2 years of study index date or have history of prior use of any combination of GLP1RA or SGLT2i in the previous 1-year lookback period. Confounding was accounted via nearest-neighbor pairwise propensity score (PS) matching informed by expert-identified variables meeting the disjunctive cause criterion.
The primary outcome was a composite rate of 4-point major adverse cardiovascular events (MACE): ischemic stroke (IS), myocardial infarction (MI), coronary revascularization (CV) and hospitalization for heart failure (HHF). Secondary outcomes included comparing the rates of individual components of the primary outcomes, peripheral arterial disease (PAD) as well as chronic pulmonary disease (CPD) hospitalizations and emergency room visits and atrial fibrillation between the two groups.
Results: Matched cohorts included 51,919 patients in each of the GLP1RA and SGLT2i exposure groups. Greater than 86.8% were males with mean age of 62.5 years. The rate of four-point MACE was increased in the matched cohort when compared to the GLP1 cohort (incidence rate per 100 person-years (IR)= 22.5 vs 20.4; adjusted Hazard Ratio (aHR)= 0.88 [0.85-0.92]; p= <0.001[MJ1] ). The rate of 3-pt MACE was lower in the GLP1RA group compared to the SGLT2i. (IR= 19.6 vs 17.9; aHR= 0.91 [0.87-0.95]; p= <0.001).
The secondary outcomes rates were lower in the GLP1RA group compared to SGLT2i for :  MI (IR= 12.7 vs 11.5; aHR= 0.81[0.76-0.86]; p= <0.001), IS (IR= 16.2 vs 13.8; aHR= 0.84[0.8-0.89]; p=<0.0010), Any stroke (IR=27.4 vs 24.9; aHR=0.88[0.82-0.94]; p=<0.001), and coronary vascularization (IR= 2.06 vs 1.77; aHR=0.8[0.68-0.95]; p=0.01). The rates of HHF were not significantly different between the cohorts (IR= 6.5 vs 4.44; aHR=0.82[0.64-1.04]; p=<0.097). No statistically significant difference was noted in the rates of  PAD(IR=25.9 vs 22; aHR= 0.99[0.93-1.07]; p=0.953) and atrial fibrillation (IR=41.2 vs 37.8; aHR=1.03[0.98-1.08; p=0.259), however atrial fibrillation did occur less frequently in the GLP1-RA group when limiting timeline to 90 days after therapy initiation (IR=27.5 vs 23.9; aHR=0.9[0.86-0.94]; p=<0.001) while the rates were similar at 180 days. The rates of CPD hospitalization (IR: 1.76 vs 1.42 SGLT2i ; aHR= 0.68[0.56-0.81]; p= <0.001) and emergency room visits (IR: 7.74 vs 6.21 SGLT2i; aHR= 0.85[0.78-0.92]; p=<0.001) were significantly lower in the GLP1RA group compared to SGLT2i.
Conclusions(s): Overall, the rate of 4-point MACE and 3-point MACE was significantly lower in GLP1RA group compared to SGLT2i, however, the rates of HHF were similar with numerically higher incidence rates in GLP1RA as compared to SGLT2i. No difference in the rates of Atrial fibrillation was found however the risk was lower at 90 days in the GLP1RA group however no significant difference in rates were noted between the cohorts at 180 days, indicating time varying confounders and warrants further research. Our study also showed that the rates of ER and Hospitalization for CPD were significantly lower in the GLP1RA group compared to SGLT2i in agreement. Future prospective studies should focus on ascertaining the difference between COPD and ASTHMA rates individually, differences in the rates of Atrial fibrillation with long term GLP1RA utilization as well as differences based on previous history of diabetes.
Self Assessment Question: MACE (MI, ischemic stroke, HF, CV) occurred more frequently in patients receiving an SGLT2i than patients using GLP1-RAs. (True/False)

Title: Enoxaparin for trauma-related venous thromboembolism prophylaxis: Bleeding risk with vs. without monitoring in a rural academic medical center 
Authors: Lauren Wagner, PharmD, MBA; Alena Thannikal, PharmD, BCPS, BCCCP; Michelle Budzyn, PharmD, BCPS 
Learning Objective: Evaluate trauma-related bleeding complications with or without a pharmacist-driven monitoring protocol 
Self-assessment question: True or False: In trauma patients receiving anti-Xa monitoring, the rate of clinically significant bleeding is decreased
Background/objective: Pharmacist‑driven monitoring and dose adjustment may optimize enoxaparin prophylaxis, but rates of bleeding in rural trauma patients receiving enoxaparin for VTE prophylaxis remains understudied.  This study evaluates bleeding outcomes with or without pharmacist‑driven monitoring. 
Methods: This single‑center retrospective cohort study examined adult trauma patients who received enoxaparin for trauma‑related VTE prophylaxis from 9/1/24–1/1/25, compared those with pharmacist‑driven monitoring to those without it. Included criteria were trauma patients ≥18 years who received enoxaparin during hospitalization at a Geisinger Medical Center facility. Patients were excluded if they were on hemodialysis, pregnant, had known enoxaparin hypersensitivity, or anticoagulated immediately before prophylaxis. The primary outcome was the rate of clinically significant bleeding in monitored versus non‑monitored patients and assess factors influencing complications, including traumatic brain injury (TBI), spinal cord injury, pelvic fractures, advanced age, and low body weight. Secondary outcomes include incidence of any thrombotic event. The primary outcome was analyzed using a chi-square test with associated factors evaluated through a multivariable logistic regression model in a forest plot. The secondary outcome was analyzed using Fisher’s exact test. Statistical significance was defined as α = 0.05 for all analyses. 
Results: Out of 673 patients, 324 were included in the analysis, 203 in the monitored group, and 121 in the non-monitored group. Incidence of significant bleeding occurred in 17.7% in the monitored group and 11.6% in the non-monitored group (RR 1.53, p = 0.137). Two variables, advanced age (OR 6.56, p = 0.114) and monitored/non-monitored (OR 7.93, p = 0.083), were identified to have an increased odd of bleeding. Incidence of new thrombotic events occurred in 0.5% in the monitored group and 2.5% in the non-monitored group (RR 0.20, p = 0.149).
Conclusion: The results of this study showed no statistical significance in bleeding events nor new thrombotic events between the two groups. Therefore, Anti-Xa level monitoring may be beneficial in high-risk patient populations such as advanced age, traumatic brain injury (TBI), or pelvic fractures. However, larger, more refined studies will be required to confirm these findings.

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: Bridging the gap: Impact of discharge medication provision on psychiatric readmission rates 
  
Authors: Alexis Roman, PharmD; Madeline Corrao, PharmD; Sabra Douthit, PharmD 
 
Objective: Evaluate the impact of discharge medication delivery through a Meds to Beds (M2B) program, compared with patient pickup at a community pharmacy, on 30-day psychiatric hospital readmission rates. 

Self-Assessment Question: Which factor is most strongly associated with psychiatric hospital readmissions during transitions of care?
A. Short inpatient length of stay
B. Dose adjustments during hospitalization 
C. Medication nonadherence after discharge
D. Overuse of long-acting injectable therapies
  
Background: Psychiatric inpatients who receive discharge medications prior to leaving the facility experience significantly lower 30-day readmission rates than those discharged with prescriptions filled at an outside community pharmacy.  
 
Methods: This retrospective cohort study will use electronic medical record (EPIC) data to compare adult psychiatric inpatients discharged with medications through a Meds to Beds (M2B) program versus prescriptions filled at community pharmacies. Eligible patients will be ≥18 years old, admitted to Geisinger Behavioral Health Northeast, discharged on at least one medication, and have a primary psychiatric diagnosis; patients discharged to a state hospital or who expired within 30 days post‑discharge will be excluded. Data from August 1, 2023, to July 31, 2025, will be analyzed (estimated n=200), with 30‑day psychiatric readmission as the primary outcome with 7‑ and 14‑day readmissions as secondary outcomes; descriptive statistics and comparative analyses (Fisher’s exact tests) will be performed. 
 
Results: A total of 200 patients were included (M2B n=130, community n=70). Thirty-day readmission rates were similar between groups (16.2% vs. 15.7%; RR 1.03, 95% CI 0.58-2.01; p>0.999). No meaningful differences were observed at 7 days (5.2% vs. 4.8%; RR 1.08, 95% CI 0.31-3.85) or 14 days (9.9% vs. 7.8%; RR 1.27, 95% CI 0.49-3.36). Overall event rates were low, resulting in wide confidence intervals and limited precision of estimates.

Conclusions: Meds to Beds was not associated with lower psychiatric readmission rates compared to community pharmacy pickup. These findings suggest medication delivery alone may have limited impact on readmissions and highlight the need to address broader factors influencing outcomes during transitions of care.

Authors: Michael Remmel, PharmD; Memar Ayalew, PharmD, BCIDP, AAHIVP

Objectives: Evaluate the impact of provider education and an ED-specific outpatient order set on guideline-concordant antibiotic prescribing for CAP, characterize drivers of non-adherence, and assess associated clinical outcomes and adverse drug reactions.

Background: 
Community-acquired pneumonia (CAP) is a common cause of emergency department (ED) visits, and antibiotic prescribing often deviates from guideline selection, dose, and duration of therapy. This study evaluated whether an order set intervention improved adherence to local CAP guidelines.

Methods:
This retrospective, , pre-post intervention quasi-experimental quality improvement study evaluated CAP management at Walter Reed National Military Medical Center ED. Patients were included if >/= 18 years of age, diagnosed with CAP in the ED and received oral antibiotics upon discharge between July 1, 2025 and January 31, 2026 October 16, 2025, used as the pre- and post-intervention cutoff. Prescribing trends were compared before and after intervention which included provider education, implementation of an emergency department-specific updated outpatient protocol and creating a corresponding order set in the electronic medical record (EMR)Patients with recent oral or intravenous antibiotic exposure, recent hospitalization or ED visits, concurrent infections, no discharge antibiotic, or poor demographic data were excluded. The primary outcome was rate of  local guideline-concordant antibiotic therapy selection ; secondary outcomes included regimen selection, dose, frequency, duration, and treatment outcomes. Descriptive statistics were used to summarize prescribing patterns and outcomes.

Results:
Of 111 screened patients, 82 patients met inclusion criteria, including 28 pre-intervention and 54 post-intervention. Guideline-concordant antibiotic selection increased from 10.7% in the pre-intervention period to 22.2% post-intervention period. Prescriptions for 3- to 5-day treatment durations increased from 35.7% to 53.7%, while durations of at least 6 days decreased from 64.3% to 46.3%. Use of non-preferred antibiotic regimens categorized as “other” decreased from 50.0% to 25.9%. Common drivers of nonadherence were medication selection (36.0% vs 40.5%), duration (24.0% vs 21.4%), and multiple discordant components (36.0% vs 35.7%).

Conclusion:
Education and outpatient CAP order set implementation were associated with improved guideline-concordant prescribing in the ED, particularly for antibiotic selection and shortening durations of therapy. These findings support continuing antimicrobial stewardship efforts in the ED and further order set refinement to improve discharge prescribing quality.

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.

Title: Impact of bromocriptine on suspected neurogenic fever
Authors: Maeghan Biché, PharmD; Benjamin Wilkinson, PharmD, BCCCP; Haley Kavelak, PharmD, BCCCP; Julia Bold, PharmD
Objective: Audience members will be able to describe the impact of bromocriptine on fever in patients presenting with suspected neurogenic fever.
Self-Assessment Question: What patient population(s) may benefit most from bromocriptine use based on this study?
Background: Bromocriptine is hypothesized to have an antipyretic effect in patients with neurogenic fever, however the evidence is limited to small retrospective studies. This study aims to describe the impact of bromocriptine on neurogenic fever.
Methods: This retrospective chart review included adult patients admitted to the neurological intensive care unit (ICU) who received at least one dose of bromocriptine for suspected neurogenic fever between 6/1/2020 and 6/1/2025. The primary outcome was the change in maximum body temperature (Tmax) from the 24-hour period prior to bromocriptine administration (day 0) to the 48-to-72-hour period after initial administration (day 3). Secondary outcomes included change in Tmax from day 0 compared to 0 to 24 hours after administration (day 1) and 24 to 48 hours after administration (day 2), duration of fever, ICU length of stay (LOS), hospital LOS, and mortality 30 days after bromocriptine administration. Outcomes were analyzed by Mann-Whitney U test.
Results: A total of 75 patients were included in the analysis with a median age of 53 years. Administration of bromocriptine resulted in a significant decrease in temperature on day 3 (38.8 ºC vs 38.2 ºC, p < 0.001). The median dose of bromocriptine administered was 15mg on day 1, 30mg on day 2, and 40mg on day 3. Patients with a traumatic injury (n=22) had a greater reduction in fever compared to those with a non-traumatic injury at 72 hours (-0.8 ºC vs -0.5 ºC, p=0.002). The median duration of fever was 2 days. Hypotension occurred in 27 patients after administration, and 20 patients experienced nausea.
Conclusion: In patients with suspected neurogenic fever, bromocriptine may be an option for temperature reduction when added to other antipyretics. Patients with traumatic injury demonstrated a greater reduction in fever, suggesting greater efficacy in this population. Further investigation into dosing strategies is needed.

Title: Appropriateness of venous thromboembolism prophylaxis prescribing in acutely ill medical patients 

Authors: Seharpreet Sethi, PharmD; Geoffrey Arentz, PharmD, BCPS; Christine Higgins, RPh, BCPS 

Learning Objective: Audience members will be able to identify patients who are appropriate to receive venous thromboembolism (VTE) prophylaxis.  

Self Assessment Question: At the conclusion of my presentation, the participant will be able to recognize appropriate prescribing of VTE prophylaxis.

Background/Objective: The purpose of this study was to identify the appropriate usage of VTE prophylaxis in the inpatient setting. Guidelines for VTE prophylaxis refer to the IMPROVE VTE and Bleed scores as a method of risk assessment before starting. 

Methods: This retrospective chart review included patients >18 years admitted in three medical floors, medical, and cardiac ICU, who received VTE prophylaxis between July 1 and August 8, 2025. The exclusion criteria included admissions for bleeds, pregnant and postpartum patients, repeat admissions, and therapeutic anticoagulation orders. The primary objective was the percentage of inappropriate VTE prophylaxis prescribing, based on IMPROVE VTE and IMPROVE Bleed scores. Secondary outcomes include bleeding 48 hours after last dose of prophylaxis given, the percentage of patients ineligible based on their IMPROVE VTE score, percentage of patients ineligible based on their IMPROVE Bleed score, and percentage of appropriate VTE prophylaxis prescribing in the ICU compared to non-ICU settings.  

Results: A total of 248 patients met the inclusion criteria, and 64 patients were excluded, leading to a total of 184 patients being studied. The primary objective revealed that 69% of total included patients had inappropriately received VTE prophylaxis based on their IMPROVE scores. Looking at the secondary outcomes, 3 patients experienced a bleed. 2 of these patients were ineligible to receive prophylaxis, while 1 was eligible. 67% of patients deemed ineligible for VTE prophylaxis did not meet criteria to start due to a low IMPROVE VTE score. Overall, percentages of ineligible and eligible patients were similar between ICU and non-ICU patients.. 
 
Conclusion: Application of the IMPROVE VTE and Bleeding risk scores to assess appropriateness for VTE prophylaxis suggests that prophylaxis may be overprescribed in the inpatient setting, including both ICU and non-ICU populations. Pharmacists in different practice areas should continuously evaluate a patient’s risk of VTE and bleeding to potentially deescalate prophylactic prescribing, which could improve patient satisfaction and cost savings. 

Title: Evaluation of a Pharmacy-Managed Weight Loss Program in the VA Healthcare System One Year Post-Implementation
Authors: 
Melissa Contreras PharmD; Tanvi Patil, MPH, PharmD, BCPS, DPLA; Brandi Sugonis, PharmD, BCACP; John Minchak, BS, PharmD, MBA, BCPS, BCGP; Alamdeep Kaur, PharmD, BCPS; Jena Willis, PharmD, Kayla Williams

Presentation Objective: At the conclusion of my presentation, the participant will be able to evaluate the effectiveness of a pharmacy-managed weight loss program within the VA Healthcare System one year after its implementation.
 
Self-Assessment Question: True or false: There is greater follow-up in patients managed by a CPP compared to a non-CPP.

Background: Obesity is a chronic disease associated with significant morbidity, mortality, and healthcare costs, yet it remains undertreated despite the availability of effective pharmacologic therapies. Weight loss medications have demonstrated meaningful reductions in body weight, along with improvements in cardiovascular outcomes however, clinical inertia has limited their use. Contributing factors include limited provider time and lack of healthcare resources. Clinical Pharmacy Practitioners (CPPs) can fill this gap by supporting medication optimization, education, and monitoring to improve weight management care.  This study aims to evaluate the impact of pharmacist managed weight loss program (PMWP) at a single center rural VA healthcare system one year post implementation.

Methods: This single-center quality improvement study evaluated a PMWP implemented in collaboration with VA MOVE! program dietician (weight management program for veterans). Weight loss medications were managed by either a CPP or other providers.  Patients with less than 6 months of follow-up after medication initiation, therapy discontinuation, or those transferred to another facility within a 6-month period were excluded. The primary outcome was to compare the proportion of patients achieving ≥5% weight loss within 6 months in the CPP versus non-CPP groups. Secondary outcomes included the proportion of patients achieving ≥5% weight loss by the end of the study and the mean difference in the average weight loss % achieved between the two groups at 6 months and end of study period. Patients who were followed for >6 months an additional weight was recorded at last follow-up to calculate weight loss at the end of the study period. The primary outcome was evaluated using chi-square test or Fisher’s exact. Continuous variables were compared using Student t-test or Mann-Whitney U test.
 
Results
The preliminary analysis of our study is included currently as the data collection is still in progress. A total of 161 patients were reviewed. After applying exclusion criteria, where non-completion of at least 6 months of weight loss medication therapy was the most common reason for exclusion, the study had a sample of 54 patients to be included. The study included 47 patients in CPP group and 7 patients in non-CPP managed group. The mean age was 58.1 years, height was 69.9-inches, and weight was 324.5 lbs. Majority of patients were non-Hispanic, white male with type 2 diabetes. The most common comorbidities included type 2 diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea. The most prescribed weight loss medication was tirzepatide followed by semaglutide.
At 6 months proportion of patients who achieved at least 5% of weight loss in CPP vs. non-CPP group were 25 (71.43%) vs. 3 (42.86%) with p-value 0.197 while at the end of the study period the proportion of patients were CPP 27 (81.82%) vs. non-CPP 3 (42.86%) and p-value of 0.052 respectively. At the end of 6 months and end of study period mean weight loss in CPP vs. non-CPP group was 31.86 vs. 13.19 lbs. P-value of 0.03 and 35.69 vs. 13.71 lbs. with p-value of 0.03 respectively. The mean percent weight loss achieved in CPP vs. non-CPP group was 9.74% vs. 3.8% at 6 months and 11.54% vs.4.32% at the end of study period.
 
Conclusion
Overall, our study shows at the preliminary analyses that patients enrolled in the CPP group had higher proportion of patients achieving at least 5% of weight loss and the mean weight loss achieved was significantly higher in the CPP group as compared to the non-CPP group.

Implementation of allergy reconciliation for beta-lactam allergies

Authors: Mark Angel, PharmD; Lori Belle Slone, PharmD, BCPS; Jessica Sobnosky, PharmD, BCPS, BCIDPObjective: •Audience members will be able to apply the PEN-FAST tool during medication reconciliation to risk-stratify beta-lactam allergies.

UDIEBackground: Inaccurate beta-lactam (BL) allergy documentation limits first-line antibiotic use and promotes broad-spectrum alternatives. This study evaluates whether pharmacy led allergy reconciliation improves documentation accuracy and antimicrobial selection.Methods: This study reviewed electronic health records of patients ≥18 years with a documented beta-lactam (BL) allergy who underwent pharmacist-led allergy reconciliation between November 1, 2025, and March 1, 2026. Allergy documentation was evaluated for accuracy and clinical relevance following reconciliation. The primary outcome was the proportion of patients with updated BL allergy documentation. Secondary outcomes included the proportion of patients with antimicrobial therapy modification and BL utilization following clarification. Data were collected via retrospective chart review at study completion, de-identified, and securely stored. Descriptive statistics were used, with categorical variables such as PEN-FAST risk levels and documentation rates reported as frequencies and percentages to identify gaps between clinical reconciliation and formal documentation practices.

Results: A total of 189 patients were eligible for inclusion with 50 being randomized for analysis. Risk stratification using the PEN-FAST tool identified 14 patients (28%) as very low risk, 19 (38%) as low risk, 15 (30%) as moderate risk, and 2 (4%) as high risk. The primary outcome of updated allergy documentation was achieved in one patient (2%). Regarding secondary outcomes, no modifications to antimicrobial therapy were observed during the initial admission following reconciliation. Prior to PEN-FAST assessment, 66% of low-risk patients were already receiving BL therapy. Zero adverse drug reactions related to BLs occurred during the study period.

Conclusion: Although pharmacy-led reconciliation did not result in immediate antimicrobial therapy changes, it identified a gap between allergy risk assessment and clinical decision-making. Most patients were low or very low risk by PEN-FAST and were already receiving beta-lactams. However, improved allergy documentation provides lasting value by supporting optimized antibiotic selection in future encounters and highlights the need for better use of validated assessment tools.

References:
Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Platt R, Polk RE, Sandora TJ, Tamma PD, Trivedi KK. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(10):e51–e77.

Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet. 2019;393(10167):183–198.

Centers for Disease Control and Prevention. Antibiotic use in the United States: penicillin allergy. Atlanta, GA: US Department of Health and Human Services; 2021.

Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: a cohort study. J Allergy Clin Immunol. 2014;133(3):790–796.

Torres MJ, Adkinson NF Jr, Caubet JC, Khan DA, Kidon MI, Mendelson L, Gomes ER, Rerkpattanapipat T, Zhang S, Macy E; AAAAI/WAO 2018 Symposium Penicillin and Cephalosporin Allergy Testing Working Group. Controversies in drug allergy: beta-lactam hypersensitivity testing. J Allergy Clin Immunol Pract. 2019;7(1):40–45.

Trubiano JA, Vogrin S, Kruse O, Phillips EJ. Development and validation of a penicillin allergy clinical decision rule. JAMA Intern Med. 2020;180(5):745–752

Title: Implementation gap in mineralocorticoid receptor antagonist use in patients with heart failure with reduced ejection fraction
Authors: Oyinlola Shofolawe-Bakare, PharmD; Scott Baker, PharmD, BCPS.
Learning objective: Audience members will be able to identify reasons for non-initiation of mineralocorticoid receptor antagonist in eligible heart failure patients with reduced ejection fraction and assess whether reasons are appropriate or if interventions could have been made to prevent non-initiation.
Self-assessment question: Which of the following non-initiation reasons can an intervention be potentially made to allow for initiation of MRA on discharge without the need for continuous monitoring?
 A.) Acute kidney injury
 B.) Acute hyperkalemia
 C.) Low blood pressure
 D.) None of these
Background: The objective of the study was to review hospitalized patients with heart failure with reduced ejection fraction (HFrEF) to identify reasons for non-initiation of mineralocorticoid receptor antagonists (MRAs) at hospital discharge and evaluate readmission rates within this group. The American college of cardiology/ American heart association guidelines recommend MRAs for optimized guideline directed medical therapy (GDMT) in patients with chronic HFrEF who remain symptomatic despite optimal dosing of (renin-angiotensin-aldosterone) RAAS inhibitors, beta blockers and other standard therapies. However, their use remains suboptimal in this demographic.
Methods: A single-center retrospective cohort study in adults with a HFrEF diagnosis and LVEF < 40% who at the time of discharge were eligible to receive an MRA but either received or did not receive an MRA on discharge. The primary outcome was 30-day heart failure readmission rates between patients who were not discharged on an MRA based on the reasons for non-initiation. Secondary outcomes included 30-day and 90-day hospital readmission rates among patients discharged with vs. without an MRA and 1-year mortality.
Results: Of 278 patients screened, 218 met the eligibility criteria for the study. 121 patients received and continued MRA on discharge. 97 patients did not receive MRA on discharge. Non-initiation on discharge was determined by the physician. The reasons for non-initiation were largely undocumented for most patients. Other reasons included blood pressure, renal function, hyperkalemia or the patients were deferred to outpatient cardiology for follow-up. Hospital readmission rates in these groups were 13.0%, 11.8%, 33.3%, 0.0% and 14.3% respectively. There was no statistically significant difference in 30-day re-admission rates among the groups. For secondary outcomes, there was a statistically significant difference in 30-day (2.4% vs 19%) and 90-day (5.7% vs. 21%) hospital readmission rates among patients discharged with vs. without an MRA (p-value < 0.001). However, there was no difference in 1-year mortality in both groups (p-value = 0.50).
Conclusion: In this small, retrospective cohort study, majority of patients who were eligible for an MRA received one on discharge. In the group of patients who did not receive an MRA, reasons fell into a few categories. Although there was no difference in 30-day readmission rates within the non-MRA initiation group, this study highlights the importance of evaluating the appropriateness of non-initiation of therapy.

Title: Use of insulin NPH in patients with steroid-induced hyperglycemia

Authors: McCleary D, Van Slyke B, Schaefer M, Calder T

Learning Objective: Evaluate the effects of insulin NPH on hyperglycemia management outcomes and safety considerations.

Self-Assessment Question: Which insulin strategy best aligns with the glucose-raising pattern of glucocorticoids in steroid-induced hyperglycemia?

Background/Objective: Glucocorticoids are widely used for their immunosuppressive and anti-inflammatory effects but often cause hyperglycemia. This study evaluates the effectiveness of NPH insulin versus non‑NPH regimens in managing steroid‑induced hyperglycemia.

Methods: A two‑month retrospective chart review will be conducted from November 1, 2025, to December 31, 2025, for patients started on glucocorticoid therapy who meet inclusion criteria. These patients, identified through an automated report, will serve as the intervention‑free control period. A subsequent two‑month prospective phase from January 1, 2026, to February 28, 2026, will evaluate the insulin NPH intervention. Included patients must be initiated on glucocorticoid therapy exceeding 10 mg prednisone equivalents per dose, have two or more blood glucose readings above 180 mg/dL in the first 24 hours of therapy or a history of diabetes, and be ≥18 years old. Exclusion criteria include hypoglycemia during the current admission, treatment for DKA or HHS, or age <18. The primary outcome is the rate of blood glucose readings >180 mg/dL while on glucocorticoids. The safety outcome is the rate of hypoglycemia events.

Results: A total of 42 patients met inclusion criteria, including 24 in the retrospective control group and 18 in the prospective insulin NPH group. Baseline characteristics were comparable between groups. There was no statistically significant difference in the rate of hyperglycemia between patients managed without insulin NPH and those receiving insulin NPH (43% vs 43%; P = 0.99). Among patients with ≥2 blood glucose readings >180 mg/dL within the first 24 hours of glucocorticoid initiation, the mean rate of hyperglycemia was 52% in the non–insulin NPH group and 43% in the insulin NPH group (P = 0.39). One hypoglycemia event occurred in the non–insulin NPH group compared with four events in the insulin NPH group.

Conclusion: Insulin NPH use for steroid‑induced hyperglycemia did not result in a statistically significant reduction in hyperglycemia compared with non–insulin NPH therapies. However, the pharmacodynamic profile of insulin NPH closely aligns with glucocorticoid‑related glucose elevations. Optimized dosing strategies, standardized protocols, and larger studies are needed to better define its role in managing steroid‑associated hyperglycemia.

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

Title: Correlating application screening rubric categories with interview invitations at a postgraduate year 1 (PGY1) residency program
Authors: Paige Spencer, PharmD, Gail M. Sanchez, PharmD, BCPS, DPLA and Xia Thai, PharmD, BCPS; Cambridge Health Alliance (CHA), Cambridge, MA.
Objective: At the conclusion of the presentation, audience members will be able to state the process used to evaluate an application screening rubric for a PGY1 residency program.
Self Assessment Question: What is the importance of evaluating an application screening rubric for PGY1 residency programs discussed today?
Background: Identify which screening rubric categories are significant predictors of PGY1 interview offers.
Methods: This retrospective quality improvement project evaluates the scoring of PGY1 residency applications utilizing our institution’s ten category weighted rubric. Completed applications received through the online centralized application service by the cycle deadline of the Phase 1 Match from 2017-2024 are included and de-identified using a random number generator. The candidates invited for an interview serve as the test group and those not invited serve as the control group. A logistic regression analysis will be performed. The primary outcome will be the correlation of each individual rubric category score and whether or not the candidate was offered an interview. Secondary outcomes will include the correlation between interview invitation and the practice area of the reviewer and the pharmacy school location. We hypothesize the correlation analysis will determine how to best modify the screening rubric to improve efficiency while still offering interviews to highly qualified candidates.
Results: Our program received 441 completed applications from 2017 to 2024. We excluded 12 applications due to incorrect documentation of screening scores leaving 429 applications included in the final analysis. Of the 429 applicants, 209 (49%) received an interview offer. In the final multivariate logistic regression, the overall impression variable was excluded to address multicollinearity, while publications and other skills were removed due to a lack of statistical significance. The resulting model demonstrated a robust fit (McFadden’s R2= 0.32, p<0.001), identifying seven rubric categories as significant predictors of interview offers: grades, leadership, letter of intent, letter of recommendation, presentations, rotations, and work experience.
Conclusion: Based on our results and the relative importance of each category to our institution, the authors plan to modify the screening rubric for future PGY1 recruitment cycles. These changes aim to improve efficiency while continuing to identify highly qualified candidates.