2026 Eastern States Conference

Authors
Allison Pollina PharmD, Maricelle Monteagudo-Chu PharmD, BCPS, BCIDP, Adam Wos MD, David Galinkin MPH, DO, Gregory Haggerty PhD, Tyler Yarema, PharmD

Background/Objective
To evaluate the impact of removing pre-checked urine culture orders from emergency department order sets on urine culture ordering, antibiotic prescribing, length of stay, and 30-day hospital readmissions or ED visits attributable to UTI.

Methods
Pre-checked urine culture orders were removed from 10 ED order sets in 3 phases between May 2024 and March 2025 (May 3, September 10, and March 27). This retrospective chart review included adult patients presenting to the ED during the pre-intervention (02/01/24 – 04/30/24) and post-intervention (04/01/25 – 06/30/25) periods who had urinalysis performed, including those admitted to the hospital. Patients were excluded if they were less than 18 years, had urinalysis ordered outside of the ED, or were treated with antibiotics for an indication other than a UTI. The primary endpoint was to assess the impact on the number of urine cultures ordered and performed, comparing 3 months before and after the intervention. Secondary endpoints included evaluating the influence on antibiotic prescribing patterns, such as initiation, selection, and duration, hospital length of stay for admitted patients, and readmission to the hospital or ED within 30 days from the initial encounter due to UTI.

Results
A total of 271 patient charts were reviewed, of which 200 patients (100 from both the pre- and post-intervention groups) met the inclusion criteria. Baseline characteristics were comparable between arms except for indications for urine culture ordering in the post-intervention phase. Analyses following the removal of pre-checked urine cultures from 10 ED order sets revealed a 38.8% and 27% reduction in the number of urine cultures ordered and performed, respectively. We observed no difference in the number of patients started on antibiotics for abnormal urinalysis or urine culture, a negligible decrease of 6% in average antibiotic treatment duration, and a 50% increase in average length of stay amongst admitted patients.

Conclusion(s)
The removal of pre-checked urine culture orders from ED order sets reduced the number of cultures ordered and performed without compromising patient safety. A more judicious approach to urine culture ordering was seen in the post-intervention phase. Although an increase in ED visits and hospital readmissions within 30 days due to UTI were observed in the post intervention period, they were not found to be statistically significant when compared to the pre-intervention.

Title: Clinical outcomes associated with ertapenem use in hypoalbuminemia: a retrospective cohort study
Authors: Allison Kang, PharmD; Antoinette Acbo, PharmD, BCIDP; Sarah Valiante, PharmD, BCIDP; Andy Hui, PharmD, BCPS; Jimmy Gonzalez, PharmD, MPH, BCPS
Learning Objective: Evaluate clinical outcomes associated with ertapenem use for treatment of gram-negative bloodstream infections (GN-BSI) in patients with hypoalbuminemia and normoalbuminemia
Self Assessment Question: True or false: Hypoalbuminemia is associated with worse clinical outcomes compared to normoalbuminemia in patients receiving ertapenem for the treatment of gram-negative bloodstream infections.
Background: Evaluate clinical outcomes associated with ertapenem use for treatment of gram-negative bloodstream infections (GN-BSI) in patients with hypoalbuminemia and normoalbuminemia
Methods: This retrospective chart review included adults with gram-negative bloodstream infections (GN-BSI) who received ertapenem and had a serum albumin level during their index admission between January 2020 and May 2025, excluding patients who died within 48 hours of appropriate treatment, received fewer than 3 ertapenem doses while admitted, were pregnant, or had an index organism resistant to ertapenem. The primary outcome was a composite of 30-day mortality, bacteremia recurrence between 7 and 30 days from the index culture, clinical failure from day 3 of ertapenem until discharge or end of therapy (whichever came first), and 30- and 90-day readmission. Primary analysis was conducted using Χ² or Fisher’s exact tests, and secondary analysis was conducted using multiple logistic regression.
Results: A total of 273 patients met inclusion criteria – 146 in the hypoalbuminemia group (serum albumin < 2.5 g/dL) and 127 in the normoalbuminemia group (≥ 2.5 g/dL). Demographics were similar between cohorts, though ICU admission was more common in the hypoalbuminemia group, and infection source varied between the two groups. The hypoalbuminemia group experienced higher rates of the composite endpoint (72% vs 48%, p < 0.001), 30‑day mortality (21% vs 7.1%, p = 0.002), and treatment failure (68% vs 46%, p < 0.001). Hypoalbuminemia, ICU admission, and steroid use were associated with increased odds of the composite after adjusting for covariates.
Conclusion: In adults receiving ertapenem to treat susceptible GN-BSI, hypoalbuminemia was associated with increased rates of the composite outcome, 30-day mortality, and treatment failure. Larger prospective studies are needed to confirm these findings.

Authors: Alexander J. Ruehman, PharmD; Mandee Booth, PharmD, BCIDP; Alexander Cain, PharmD BCIDP 
Learning Objective: Audience members will be able to describe appropriate treatment regimens for low-risk AmpC infections
Self-Assessment Question: Which of the following is the most appropriate treatment option for susceptible Morganella morganii blood stream infection? A. Ceftriaxone B. Cefepime C. Cefazolin D. More data needed
Background/Objective: The Infectious Diseases Society of America provides guidance that ceftriaxone or piperacillin/tazobactam may be used for susceptible, low-risk AmpC isolates; however, optimal treatment remains controversial.
Methods: This single-center retrospective study included adults with blood cultures growing S. marcescens or M. morganii from January 1, 2020 to December 31, 2024. Patients were excluded if isolates were resistant to ceftriaxone (CRO) or piperacillin/tazobactam (TZP) or if definitive therapy did not include CRO, TZP, cefepime, or a carbapenem. Data collected included demographics, level of care, infection source, and treatment duration. The primary outcome was clinical treatment failure, defined as death during therapy, 30-day all-cause mortality, escalation from CRO or TZP during definitive therapy, or infection recurrence within 30 days. Secondary outcomes included Clostridioides difficile infection within 90 days of antibiotic completion and infection-related readmission within 30 days. Descriptive statistics summarized variables; categorical data were analyzed using chi-square or Fisher’s exact tests, and multivariable analysis identified risk factors for treatment failure.
Results: A total of 103 patients were included in the study with 47 in the CRO/TZP group and 56 in the FEP/CBP group. Serratia marcescens comprised most infections (90%). Median duration of definitive and total treatment did not differ between groups. Patients in the FEP/CBP group had a longer length of stay (34.5 vs 24 days, p=0.013) and hospital-acquired infection (91.1% vs 66%, p=0.0016). Incidence of treatment failure was similar between groups (27.7% vs 25%, p=0.76) and there was no significant difference in secondary outcomes. No baseline characteristic, including age, severity of illness, immunocompromised status, or source of infection, were significantly associated with an increased risk of treatment failure.  
Conclusion: Definitive therapy with CRO/TZP was not associated with higher risk of clinical treatment failure when compared to FEP/CBP, suggesting that definitive antibiotic selection based on sensitivity results does not increase risk of treatment failure. The findings of this study are largely limited to S. marcescens infections treated with 7-14 days of therapy, and future studies are needed for other low-risk AmpC infections and those requiring treatment durations exceeding 14 days.

Title
Impact of carbapenemase production on mortality in carbapenem-resistant organisms 

Authors
Katelyn Kelsey, PharmD; Jessica Hunt, PharmD; Rasha Abouelsaadate, PharmD, BCCCP

Learning Objective
Identify the difference in 30-day all-cause mortality in carbapenem-resistant organisms (CRO) bacteremia caused by carbapenemase-producing versus non-carbapenemase-producing strains.

Self-Assessment Question
The BCID panel was positive KPC producing Klebsiella pneumoniae. What is the preferred treatment of choice?

Background/Objective
The purpose of this study is to compare 30-day all-cause mortality in carbapenem-resistant organisms (CRO) bacteremia caused by carbapenemase-producing (CP) versus non-carbapenemase-producing strains.

Methods
This multi-site, retrospective cohort study included patients >18 years of age with initial bloodstream infection caused by organisms resistant to at least one carbapenem admitted between January 1, 2018, to July 30, 2025. Patients were excluded if they were pregnant, transitioned to end of life care or comfort care prior to completion of therapy or received treatment for CRO infection < 30 days from hospital admission. The primary outcome was all-cause mortality at 30 days. Secondary outcomes included treatment failure, recurrence, development of Clostridioides difficile infection, 30-day readmission rate and hospital length of stay.

Results
 A total of 19 records of CRO-positive bacteremia patients were screened and 14 subjects with CRO were included with 2 (14.3%) CP-CRO and 12 (85.7%) non-CP-CRO. The likely source of bacteremia was similar between the two groups. There were two carbapenemase types: KPC and NDM. A total of 3 patients (21.4%) died within 30 days, all of which were non-CP-CRO. The mean hospital length of stay was 17.5 days for non-CP-CRO and 14 days for CP-CRO. No subjects tested positive for Clostridioides difficile infection. Treatment failure was seen in four subjects (28.6%), both of which were in the non-CP-CRO group. No subjects experienced recurrence < 30 days. Hospital readmission (<30 days) occurred in two subjects in the non-CP-CRO producing group.

Conclusion 
There were similar rates in 30-day all-cause mortality in CP-CRO compared to non-CP-CRO producing groups. The study’s limitations include small sample size due to the specific inclusion of only bacteremia patients. The results presented are therefore exploratory and are not to provide definitive conclusions. The trends observed in the data can be used to generate hypotheses and guide future research.

Authors: John Kim, PharmD; Daniel Abate, PharmD; Alexander Walk, PharmD, MS, AAHIVP 

Learning Objective: Describe the role of antibiotic prophylaxis in patients requiring placement of a cerebrospinal fluid (CSF) drain 

Self-Assessment Question: True or False
Current IDSA guidelines recommend against the use of prolonged antibiotic prophylaxis for EVDs

Background 
There is no clear evidence regarding the use of prolonged antibiotic prophylaxis in patients requiring a CSF drain placement. The objective is to evaluate the efficacy and safety of antibiotic prophylaxis in these patients. 

Methods  
This will be a retrospective cohort study that will analyze adult patients at Suburban Hospital Johns Hopkins Medicine that require a lumbar drain, external ventricular drain, or ventriculoperitoneal shunt placement between 05/01/2015 and 08/01/2025. Exclusion criteria will include patients with central nervous system infection upon admission, history of Clostridioides difficile (C. diff) infection on admission, and those with an existing CSF drain prior to admission. The primary efficacy outcome will be the incidence of infection post-operatively and the primary safety outcome will be the development of C.diff infection 

Results 
For the primary efficacy outcome, 4.2% of the patients or 3/72 (0.87-11.7) developed infection post-operatively. For the primary safety outcome, 1.4% of the patients or 1/72 (0.03-7.5) developed C.diff infection. 26/27 patients with EVDs were administered prolonged antibiotics. 2/45 patients with VP shunts were administered prolonged antibiotics. 

Conclusion 
At Suburban Hospital Johns Hopkins Medicine patients with EVDs and VP shunts have low rates of post-operative and C. diff infection. Prolonged antibiotic use is most prevalent with placement of EVDs compared to VP shunts. The efficacy and safety of prolonged antibiotic use remain uncertain Future trials that include a comparator group and focus on EVDs may provide stronger evidence to support guideline recommendations

Primary Author: Glory Petnkeu, PharmD
Additional Authors: Jessica Colmerauer, PharmD, BCIDP
Learning Objective: Audience members will be able to identify the potential antimicrobial stewardship impact of transitioning from methicillin-resistant Staphylococcus aureus culture to polymerase chain reaction nasal screening in hospitalized adults.
Background/Objective: Evaluate whether switching from MRSA culture to MRSA PCR at Howard University Hospital reduced the duration of empiric anti-MRSA therapy in hospitalized adults.
Methods: This single-center, retrospective, observational pre/post cohort study at Howard University Hospital included hospitalized adults aged 18 years or older who received empiric anti-MRSA therapy for at least 24 hours and had MRSA testing collected within 24 hours of antibiotic initiation. Patients with prior MRSA screening within 1 week, confirmed MRSA infection from another culture source, pregnancy, hospital stay under 2 days, or death within 2 days of admission will be excluded. The pre-intervention group included patients screened by MRSA culture from August 1 to November 1, 2024, and the post-intervention group included patients screened by MRSA PCR from August 1 to November 1, 2025. The primary endpoint is duration of anti-MRSA therapy; secondary endpoints are time to MRSA result, time to therapy change after result availability, rate of acute kidney injury, and length of stay. Data will be analyzed using Student’s t-test and chi-square testing.
Results: Ninety patients were included (47 culture, 43 PCR). Mean empiric anti-MRSA therapy duration decreased from 81.82 to 56.77 hours after PCR implementation, but this was not statistically significant (p = 0.2401). Time to MRSA result decreased from 26.49 to 2.32 hours (p = 0.0001). Time to therapy change also decreased from 52.88 to 31.76 hours but was not statistically significant (p = 0.1916). AKI and hospital length of stay did not differ significantly between groups.
Conclusion: Implementation of rapid MRSA PCR significantly shortened result turnaround time and may help support earlier review of empiric anti-MRSA therapy. Although reductions in therapy duration and time to therapy change were not statistically significant, the findings suggest a practical stewardship benefit and support further evaluation in larger, more targeted patient groups.
Self-Assessment Question: 
What impact can faster methicillin-resistant Staphylococcus aureus polymerase chain reaction result turnaround have on antimicrobial stewardship in hospitalized adults?
A. It can delay narrowing of antibiotic therapy until final culture results are available
B. It can support earlier discontinuation or narrowing of unnecessary broad-spectrum antibiotic therapy
C. It can require broader antibiotic coverage for a longer duration
D. It can eliminate the need for antimicrobial stewardship review

A Quality Improvement Project: Effect of Pharmacist Intervention on Inappropriate Cephalosporin Prescribing for Enterococcal Urinary Tract Infections (UTIs) in the Outpatient Setting 
Strawser B, PharmD; Lombardi N, PharmD; Logsdon J, PharmD
Background
Cephalosporins are frequently prescribed empirically for outpatient urinary tract infections (UTIs); however, enterococcal species are intrinsically resistant, making continued therapy inappropriate once urine culture speciation is available. Prior internal monitoring identified persistent continuation of cephalosporins for enterococcal UTIs despite existing education and decision support, indicating a gap in outpatient antimicrobial stewardship processes.
Local Problem
A subset of adult outpatients continued to receive ineffective cephalosporin therapy after urine cultures identified enterococcus species, representing inappropriate antibiotic use and a target for process improvement.
Methods
This quality improvement initiative evaluated a pharmacist-driven prospective audit and feedback intervention embedded within existing outpatient antimicrobial stewardship workflows. A Best Practice Advisory identified adult outpatients prescribed a cephalosporin with urine cultures positive for enterococcus species between September 2025 and March 2026. Pharmacists reviewed eligible cases and communicated antibiotic optimization recommendations to prescribing providers as appropriate. Outcomes were assessed using retrospective electronic health record review comparing patients who received pharmacist intervention with contemporaneous controls managed under standard workflows. Adults ≥18 with an active cephalosporin order within 7 days were included; inpatient cases or polymicrobial UTIs were excluded. The primary outcome was continuation of inappropriate cephalosporin therapy after culture speciation. Secondary outcomes included time to antibiotic change and 30‑day UTI-related healthcare utilization (ambulatory visits, emergency department visits, and inpatient admissions).
Results
Of 348 alerts generated, 146 patients met inclusion criteria (74 control; 72 intervention). Continuation of inappropriate antibiotic therapy occurred in 24.3% of control patients compared with 2.8% of patients receiving pharmacist intervention (p<0.001). Mean time to antibiotic change was 27.1 hours in the control group and 21.1 hours in the intervention group (p=0.17). UTI-related follow-up occurred in 16.2% of control patients and 12.5% of intervention patients, with fewer emergency department visits and hospital admissions observed in the intervention group.
Conclusions
Integration of pharmacist-led prospective audit and feedback into outpatient workflows significantly reduced inappropriate cephalosporin use for enterococcal UTIs. These findings demonstrate the effectiveness of leveraging existing stewardship infrastructure to improve prescribing practices and support ongoing local process improvement.
Self-Assessment Question:
A urine culture for an outpatient with a UTI grows Enterococcus species while the patient is receiving empiric cephalosporin therapy. What is the most appropriate next step?
A. Continue the cephalosporin since the patient is already improving
B. Discontinue the cephalosporin and switch to an antibiotic active against Enterococcus
C. Extend the duration of cephalosporin therapy to ensure eradication
D. Wait for repeat cultures before making any antibiotic changes

Title: 
Impact of a Bayesian clinical decision support tool on time to appropriate antimicrobial therapy in gram-negative bacteremia infections

Authors:
Jenna Mangan, Craig Worby, Rebecca Wang, Julie Ann Justo

Learning Objective:
Describe whether implementation of the clinical decision support tool pRxcision® reduces time to appropriate antibiotic therapy compared with standard clinical decision-making.

Background:
By integrating electronic health record inputs with Bayesian inference, this study will investigate whether pRxcision® can accelerate the identification and administration of appropriate antimicrobial therapy in gram-negative bacteremia.

Methods: 
This single-center observational cohort study includes adult patients hospitalized at Dartmouth-Hitchcock Medical Center with gram-negative bloodstream infections who received at least one dose of empiric antibiotics. Patients will be assigned to pre- or post- implementation groups based on whether they were admitted during the six months before or after the launch of the pRxcision® clinical decision support tool. Patients will be excluded if they have polymicrobial bacteremia, were discharged or deceased before final blood culture results, or experienced recurrent gram-negative bloodstream infections during the same hospitalization. Outcomes for both groups will be compared, with data collected before and after implementation to evaluate changes over time. The primary goal is to evaluate whether the Bayesian model used in pRxcision® improves time to appropriate antibiotic therapy compared to standard clinical practice in gram negative bloodstream infections.

Results : 
Data collection remains ongoing, as a number of operational challenges encountered during implementation have delayed the original timeline. The anticipated go-live date for pRxcision® at DHMC was initially February 2026; however, due to slower-than-expected development and various obstacles, it has been postponed to October 2026. While the implementation was originally estimated to require approximately 32.5 hours from the DHMC information technology (IT) team, the average time invested by DHMC IT resources to date has reached 170 hours. 

Conclusions: 
If successful, DHMC will be the first institution in the United States to integrate pRxcision® into the Epic® electronic health record. As a result of unforeseen implementation challenges within Epic® that remain unresolved, the initial project timeline has been delayed. Despite these setbacks, the use of pRxcision® has the potential to significantly improve outcomes for patients with gram-negative bacteremia. 

Self-Assessment Question:
All of the following are stages along the technical implementation cycle EXCEPT:
a.    Innovators
b.    Early Adopters
c.    Late Majority
d.    Stalwarts

Title: Theoretical implementation of a rapid antibiotic susceptibility testing system on time to appropriate therapy: a descriptive analysis on improving patient outcomes    
Primary Author: Kirstin Wade, PharmD, MBA; Larissa Coyle, PharmD, BCPS, BCIDP; Tanner Bross, PharmD, BCPS, BCIDP 
Learning Objective:  
At the conclusion of this presentation, participants will be able to describe how a rapid antimicrobial susceptibility testing system can potentially reduce the duration of broad-spectrum antibiotics.  
Background/Objective:  
Time to susceptibilities at our institution is at least 48 hours. The objective was to evaluate the theoretical time to targeted antibiotic therapy using data from the Vitek® Reveal™ system in patients previously treated for gram negative bacteremia.   
Methods:  
This was a retrospective chart review of 100 adult patients with a positive blood culture for a monomicrobial gram negative organism between January 1, 2024, to June 30, 2025. Patients were excluded if they were terminally ill, comfort care, had a secondary infection, or had organisms that could not be specifically identified utilizing the Verigene®. The primary outcome was to compare the duration of broad-spectrum antibiotics with and without the addition of the system; secondary outcomes were to identify patient outcomes that could be impacted by the system such as 30-day readmissions, length of stay, Clostridioides difficile infections. 
Results: Ninety-nine patients were included in the trial. The average time saved for all ninety-nine patients was 23.3 hours. The addition of the Vitek® Reveal™ could have benefited 42 patients. The average time saved for these 42 patients was 54.9 hours. There were 8 patients with a 30-day infection-related readmission. Only 1 patient had a Clostridioides difficile infection in the 30 days post-discharge. The average length of stay was 7.7 days. The average duration of inpatient antibiotics was 6.55 days, and the average total antibiotic duration was 14.85 days.  
Conclusions: The results of this study show that the addition of the Vitek® Reveal™ system could theoretically reduce the time to targeted antibiotic therapy. The total duration of therapy was longer than expected, and further evaluation is needed to determine how antibiotic duration can be decreased at our institution.  
Self-assessment question: The theoretical implementation of the Vitek Reveal AST system could have saved an average of how many hours of inappropriate antimicrobial therapy for the total study population?
A. 6.55 hours
B. 23.3 hours
C. 42.0 hours
D. 54.9 hours

Title: Doxycycline vs azithromycin in combination with a beta-lactam for the treatment of community-acquired pneumonia in hospitalized patients 
Authors: Ashley Eadie, PharmD, Michael Parks, PharmD, BCPS 
Objective: Compare the impact of doxycycline vs azithromycin on hospital length of stay for the treatment of community-acquired pneumonia (CAP) 
Self-assessment Question: True/False - Doxycycline in combination with a beta-lactam is currently preferred for the treatment of CAP 
Background: Current preferred treatments for CAP include combination therapy with a beta-lactam and a macrolide or monotherapy with a respiratory fluoroquinolone. Doxycycline in combination with a beta-lactam is considered an alternative option. This study was designed to evaluate the effectiveness of doxycycline versus azithromycin for the management of CAP. 
Methods: This was a retrospective cohort study that included adult patients (≥18 years) hospitalized at Mary Washington Hospital with CAP, defined by primary diagnosis of CAP and chest radiographic evidence of pulmonary infiltrate within 48 hours of admission who received a beta-lactam plus either doxycycline or azithromycin for at least 48 hours. Exclusion criteria included patients that received both doxycycline and azithromycin during hospitalization, had respiratory comorbidities (e.g., chronic obstructive pulmonary disease, cystic fibrosis), were immunocompromised (e.g., active chemotherapy, HIV, history of transplant), had a diagnosis of COVID-19, were pregnant, had multiple sites of infection, were recently hospitalized (within 10 days), or were prisoners. The primary outcome was hospital length of stay. Secondary outcomes included escalation of antibiotics, total antibiotic duration, 30 day readmission, in-hospital mortality, and adverse effects, such as development of cardiac arrhythmias and esophagitis. 
Results: Among the 89 patients included, 79 were in the azithromycin group and 10 were in the doxycycline group. There was no statistical difference observed in the hospital length of stay between the azithromycin and doxycycline group (4.7 vs. 5.8 days; P=0.12). There was no statistical difference in escalation of antibiotics (P=0.32), total antibiotic duration (P=0.26), 30-day readmission (P=0.28), in-hospital mortality (P=0.72), development of arrhythmias (P=0.53) or development of esophagitis (P=1.0).  
Conclusion: Hospitalized patients with CAP who were treated with doxycycline vs azithromycin in combination with a beta-lactam showed no significant differences in primary or secondary outcomes. Larger, randomized, controlled trials are needed to further evaluate the effectiveness between the two groups. 

Title: Evaluation of a pharmacist-led hepatitis C testing and counseling protocol on attainment of sustained virologic response at 12 weeks

Authors: Ethan Chandler, PharmD; Jacob Osborne, PharmD, MBA, BCIDP; Leigh Ann Keeton, PharmD, BCPS, BCIDP

Learning Objective: Discuss potential role inpatient pharmacists have in HCV identification and treatment initiation

Background: This study aims to assess the impact of a community hospital's pharmacist-led hepatitis C (HCV) testing and counseling protocol on the achievement of sustained virologic response at 12 weeks (SVR12).

Methods: De-identified charts of patients aged 18 years or older from January 1 to April 30, 2023 (pre-implementation period) and January 1 to April 30, 2025 (post-implementation period) will be selected for retrospective review if they had an active HCV infection as evidenced by a positive HCV viral load. Patients previously treated with DAAs, pregnant patients, deceased within 90 days following a positive HCV RNA result were excluded from analysis. The primary endpoint compared rates of SVR12 between the two periods. Secondary endpoints assessed the mean time between discharge and initial outpatient follow-up, rates of referral to appropriate outpatient treatment, rates of complete HCV follow-up appointment adherence, and rates of identified drug-drug interactions between the two groups. Additional reported information will include patient demographics, HCV genotypes, and rates of hepatitis A and B vaccinations.

Results: A total of 160 patients within the pre-implementation period (PIP) and 183 patients in the post-implementation period (POP) met inclusion criteria. The rates of SVR12 were not statistically significant between the two groups (16.9% vs. 20.8%, p = 0.408). A shorter average time between discharge and initial outpatient follow-up appointments was observed in the POP (68.5 days vs. 82.3 days), and a higher proportion of patients in the POP were referred to appropriate outpatient follow-up (79.8% vs. 68.8%). Patients in the Rates of complete outpatient follow-up (82.6% vs. 79.9%) were similar between the two groups. Rates of hepatitis A and B vaccinations and identified drug-drug interactions were low in both groups.

Conclusion: The pharmacist-led HCV testing and counseling protocol did not significantly alter the observed rates of SVR12, but it was associated with improved patient linkage to outpatient follow-up and shorter follow-up times from discharge. Poor rates of outpatient appointment adherence impacted the observed rates of SVR12; further protocol adjustments should be aimed at implementing measures to improve appointment adherence.

Title: Improvement of pharmacist’s antimicrobial stewardship interventions through electronic health record technology

Authors: Tyler E. Merrill, PharmD; Craig P. Worby, PharmD, BCIDP, BCCCP, BCPS; Julie Ann Justo, PharmD, MS, FIDSA, BCPS; Russell D. Poisson, PharmD

Learning Objective: Enhance pharmacists’ ability to optimize antimicrobial stewardship (AMS) interventions through the use of enhancements to the AMS module of the electronic health record (EHR).

Background/Objective: The primary objective of this study was to improve the quality and quantity of pharmacist’s antimicrobial stewardship interventions. The secondary objective of this study was to improve the actionability of AMS prompted scoring rules.

Methods: From October 1st, 2025, through May 1st, 2026, data was collected from the EHR to identify pharmacist AMS interventions. This multi-phase project began with updating the antimicrobial scoring rules in the EPIC Bugsy model. Investigators reassessed and ranked these rules by clinical importance. Based on this ranking, the AMS display was redesigned with informatics support to improve usability. In Phase I, an online survey was conducted for pharmacists to provide their thoughts and feedback on the previous AMS system. In this survey, pharmacists selected Bugsy alerts they perceived as most and least useful, voted on Bugsy’s compatibility with workflow, and ranked ease of use and navigation. In Phase II, a follow-up survey assessed pharmacist perspectives on the redesigned system and compared results to baseline responses. The updated scoring display and alert system aimed to improve the quality of Bugsy alerts and its incorporation within pharmacist’s daily responsibilities.

Results: Pre-update survey results (n=14) found bug–drug mismatch (24%) and IV-to-PO conversion (19%) as the most useful Bugsy alerts, while duplicate coverage (27%) was selected as the least useful. Daily use was 57%. The two most common workflow fits were “somewhat well” (57%) and “very well” (21%); mean usability score was 2.43 out of 5. Post-update survey results (n=13) at 2 months showed bug–drug mismatch (38%) and restricted antimicrobial alerts (15%) as most useful; days of therapy (30%) was ranked least useful. Daily use rose to 62%. Workflow ratings were more dispersed with “somewhat well” (31%), “very well” (23%), “somewhat poorly” and “very poorly” (38% combined). Mean usability score improved to 2.15 out of 5.

Conclusion: After the Bugsy revamp, perceived usefulness of bug-drug mismatch alerts, daily use, and overall usability improved. Workflow compatibility ratings were mixed from pre- and post-update survey results. Some alerts, including days of therapy, warrant refinement to improve actionability. Future work should prioritize pharmacist-driven improvements, alert customization, and include clinical stewardship outcomes to better assess Bugsy’s impact.

Self-Assessment Question:
Which of the following best reflects the goals of enhancing pharmacist’s AMS interventions?

1. Decrease pharmacist interventions to improve workflow efficiency.
2. Improve both the effectiveness and frequency of AMS interventions while optimizing scoring rule usability.
3. Eliminating AMS scoring systems in favor of physician-led decision-making.
4. Prioritizing antimicrobial cost reduction rather than clinical outcome consideration.

Authors: Sebastian Smreczak PharmD, Mark Adams PharmD, BCPS, Laura Truhlar PharmD, BCCCP

Learning Objective: Audience members will be able to describe the use of dalbavancin for endocarditis and osteomyelitis

Background/Objective: Assess the impact of dalbavancin protocol use for decreasing hospital stay in patients on long term IV antibiotics for osteomyelitis or endocarditis.

Methods: Data for this retrospective cohort study was collected from July 1st, 2024 to April 30th, 2026.  Patients included were 18 years and older with a diagnosis of osteomyelitis or endocarditis who received initial IV antimicrobials at Elliot Hospital. Patients were excluded if they were pregnant or incarcerated. Education was disseminated to providers and pharmacists on dalbavancin protocol treatment. The primary outcome is the number of hospital days decreased using dalbavancin protocol compared to standard therapy. Secondary outcomes include frequency of the type of identified bacteria, number of patients completing outpatient therapy, number of patients lost to follow up, rate of readmission for osteomyelitis or endocarditis, patient disposition, and mortality.

Results: A total of 161 patients were randomly reviewed for the control group with 61 excluded. There were 4 patients included in the dalbavancin analysis with 2 additional having non-study indications and 1 not meeting eligibility. Patient demographics were similar between groups with only statistically significant increases in endocarditis cases and history of IV drug use or AMA in the dalbavancin group. The dalbavancin analysis was not associated with a decrease in inpatient length of stay or increase in outpatient antibiotic days compared to control. A total of 60 hospital days were avoided with the use of dalbavancin. There was no statistical difference in 30 day hospital readmission, outpatient plan compliance, or all-cause mortality.

Conclusions: Due to limited sample size and short duration, a meaningful change in hospital stay for patients on long term IV antibiotics for osteomyelitis or endocarditis was not identified. A total of 60 hospital days were avoided across four patients who received dalbavancin demonstrating potential for a meaningful impact. Further data needs to be collected for appropriate statistical analysis.

Assessment Question: Which of the following is a potential advantage of using dalbavancin for osteomyelitis and endocarditis?
● It requires daily inpatient infusions
● It facilitates outpatient treatment
● It prolongs overall duration of therapy

Authors
Joseph Lalla, PharmD; Lauren Allen, PharmD, BCIDP; Alex Matika, PharmD, BCIDP; Justin Miller, PharmD; Esrat Jahan, PharmD

Learning Objective
Identify whether oral third generation cephalosporins are as effective as ceftriaxone and vancomycin for the treatment of penicillin-non-susceptible, ceftriaxone-susceptible VGS infections.

Background/Objective
Clinical data regarding oral transition therapy for penicillin-non-susceptible, ceftriaxone-susceptible VGS infections is limited. This study evaluated the effectiveness of cefpodoxime or cefdinir for these infections.

Self-Assessment Question
(True or false): Ceftriaxone and vancomycin are superior to oral-transition therapy with cefdinir or cefpodoxime for the treatment of ceftriaxone-susceptible VGS.

Methods
This retrospective chart review evaluated patients >18 years old admitted to St. Luke’s University Health Network for treatment of penicillin-non-susceptible, ceftriaxone-susceptible VGS infections from January 2017 to December 2025. Patients were included if they received parenteral (IV)-only therapy with ceftriaxone or vancomycin and oral transition therapy with cefpodoxime or cefdinir. Sterile cultures obtained from blood, fluid, and tissue were assessed. Patients were excluded if they had deep-seated and/or polymicrobial infections or were transitioned to comfort/hospice prior to treatment completion. The primary outcome was 90-day all-cause mortality. Secondary outcomes included recurrence of infection, hospital length of stay, and treatment-related adverse events. For analysis of continuous variables, the Student’s T-test or Mann-Whitney U Test were utilized and the Chi-square or Fisher’s exact test were conducted for categorical data.

Results
A total of 409 patients were screened. Of those, 43 were included in the IV-only group and 9 in the oral transition group. The gastrointestinal tract was the most common source of infection among both groups (42.3%) and most had concomitant bacteremia (94.2%). No significant difference in all-cause mortality at 90-days was observed between the IV-only and oral transition therapy groups (9.3% vs. 11.1%; p = 1.00). In patients that received oral-transition therapy, the total duration of definitive therapy was significantly shorter (10 vs. 15 days; p < 0.01). The median hospital length of stay was significantly shorter in the oral-transition group (5 vs. 8 days, p < 0.05). No significant difference in adverse effects was observed between the groups.

Conclusions
It remains unclear if there is a difference in all-cause mortality or recurrence of VGS infections at 90 days between the IV-only and oral transition groups. However, results suggest oral transition therapy with cefpodoxime and cefdinir may significantly reduce median hospital length of stay and total duration of definitive therapy. 

Abstract Title 

Evaluating CMV Management in Solid Organ Transplant Recipients: A Step Toward Stewardship 

Authors’ Names
Ivanna Gomez Padilla, PharmD; Sara Lee, PharmD, BCID; Ian Booth, PharmD, BCTXP, Bailey Conkey, PharmD 

Learning Objective 
To characterize CMV management and outcomes in solid organ transplant recipients at the University of Maryland Medical Center

Background/Objective 
Cytomegalovirus (CMV) infection remains one of the most common opportunistic infections and a major cause of morbidity and mortality in solid organ transplant (SOT) recipients. First-line therapies for CMV treatment are associated with clinically significant toxicities, including myelosuppression and nephrotoxicity, which may necessitate dose reductions or treatment interruptions and increase the risk of breakthrough infection and antiviral resistance. Management of CMV in this population is complex and variable among providers, contributing to inconsistent care. This study aimed to characterize CMV management practices and evaluate associated clinical outcomes among adult SOT recipients treated at the University of Maryland Medical Center (UMMC), including both inpatient and outpatient transplant clinic settings, with the goal of supporting the implementation of a pharmacist-led CMV stewardship clinic. 

Methods 
A retrospective chart review was conducted including 163 adult SOT recipients with CMV infection treated between July 1, 2021, and June 30, 2025. Eligible patients had CMV DNAemia identified by blood polymerase chain reaction testing, defined as a viral load >1,000 IU/mL, or >500 IU/mL in high-risk patients (donor seropositive/recipient seronegative; D+/R−), and received CMV treatment. Patients were excluded if they underwent hematopoietic stem cells, did not meet criteria for CMV DNAemia., or did not receive CMV treatment. The primary outcome was the incidence of CMV-related hospitalization.  

Results 
Median CMV treatment duration was 47 days (IQR 29–77) and did not significantly differ between risk groups (p=0.27). High-risk (D+/R−) recipients demonstrated a significantly longer time to CMV viral clearance compared to intermediate-risk (R+) recipients (35 vs 29 days, p=0.017). Valganciclovir was the predominant agent used for secondary prophylaxis, with hematologic toxicity representing the primary reason for antiviral modification. Drug-resistant CMV and breakthrough CMV occurred in 4.5% and 11.7% of patients, respectively.

Conclusions 
High-risk CMV serostatus was associated with delayed viral clearance, highlighting the complexity of CMV management in solid organ transplant recipients. Broad variability in treatment duration and higher numerically observed breakthrough CMV rates in D+/R− recipients further support the need for closer monitoring and individualized antiviral management. Overall, these findings identified practice gaps in CMV monitoring and antiviral management at UMMC and support the development of a pharmacist-driven CMV stewardship clinic to improve early intervention, optimize antiviral use, and standardize care for high-risk patients. 

Self-Assessment Question 
Which management strategy best reflects an effective CMV stewardship approach in solid organ transplant recipients?
A. Maintaining uniform antiviral strategies across all recipients to minimize variation in care
B. Escalating antiviral therapy solely in response to persistent DNAemia, irrespective of tolerability or immunologic risk
C. Basing treatment intensity primarily on baseline serostatus, with limited modification after initiation
D. Integrating protocol-driven care with longitudinal reassessment of virologic trends, drug toxicity, and dynamic immunosuppressive burden

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

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

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

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

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

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

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

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

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

Authors: Kyle Greenfield PharmD, Carina Mackarey Pharm D

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Authors: 
Kayleigh Early, PharmD; Brittany Thomas, PharmD, BCIDP; Alison Sabados, PharmD, BCCCP 
 
Learning Objective: 
Describe the impact of rapid molecular blood culture diagnostics on antimicrobial optimization and stewardship interventions in adult patients with bloodstream infections.
 
Background: 
Bloodstream infections are associated with increased morbidity and mortality, and delays in therapy worsen outcomes. Blood culture identification (BCID) panel implementation, with antimicrobial stewardship, may shorten time to therapy optimization.
 
Methods: 
This retrospective, pre–post cohort study evaluated adult patients aged 18 years or older admitted to WellSpan York Hospital with at least one positive blood culture in September 2023 (pre-BCID implementation) or September 2025 (post-BCID implementation). The primary outcome was time to appropriate antimicrobial therapy. Secondary outcomes included time to first antimicrobial change, time to antimicrobial escalation or de-escalation, days of therapy, and the number, type, and timing of pharmacist-driven antimicrobial interventions, as well as hospital length of stay and in-hospital mortality.

Results: 
A total of 109 patients were included (52 pre-BCID implementation, 57 post-BCID implementation) with similar baseline characteristics between groups. There was no difference in time to appropriate antimicrobial therapy (0 vs. 0 hours, p=0.746). Time to first antimicrobial change was significantly reduced (36.2 vs. 12.1 hours, p=0.007), with faster de-escalation (43.7 vs. 18.6 hours, p=0.016) but no difference in time to escalation (27.4 vs. 4.4 hours, p=0.342). Pharmacist interventions increased, with shorter time to intervention (39.2 vs. 13.6 hours, p=0.045). No differences were observed in days of therapy, hospital length of stay, or in-hospital mortality.

Conclusion: 
Implementation of a BCID panel improved the timeliness of antimicrobial optimization, including faster de-escalation and pharmacist-driven interventions. Despite these improvements, no differences were observed in time to appropriate antimicrobial therapy, time to escalation, or clinical outcomes. These findings suggest empiric regimens, guided by local antibiograms and institutional protocols, were generally appropriate, with BCID further enhancing timely antimicrobial optimization.  

Self-Assessment Question:
A hospitalized adult is started empirically on vancomycin and cefepime for suspected bacteremia. Rapid BCID panel results return. 
In which scenario should rapid identification prompt an urgent change in antimicrobial therapy? 
A. MSSA identified; patient receiving vancomycin and cefepime 
B. E. coli identified; patient receiving vancomycin and cefepime 
C. MRSA identified; patient receiving vancomycin and cefepime  
D. Candida glabrata identified; patient receiving vancomycin and cefepime

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

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

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

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

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

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

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

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

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

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

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

Self assessment question: 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• True
• False