2026 Eastern States Conference

Authors:
Alexandra Meinert, PharmD; Kelsie Ellis, PharmD, BCPPS; Alexandra Medoro, MD 

Objective:  
At the conclusion of the presentation, participants will be able to describe the safety profile of treatment doses of sulfamethoxazole-trimethoprim in patients less than two months of age.  
 
Background:  
Analyze the safety profile of sulfamethoxazole-trimethoprim (SMX-TMP) at a pediatric institution when used in patients less than two months of age or whose post-menstrual age is less than 44 weeks.  
 
Methods:  
Retrospective, single center cohort study including patients who received treatment doses of SMX-TMP (> 5 mg TMP/kg/day) and met the following age restriction: post-natal age < 2 months or post-menstrual age < 44 weeks. 
Evaluated the incidence of kernicterus, hyperbilirubinemia, hepatic dysfunction, acute kidney injury, thrombocytopenia, leukopenia, hyperkalemia, hypoglycemia, hyponatremia, anaphylaxis, or discontinuation of SMX-TMP prior to intended stop date. Data were obtained via retrospective chart review.
Data was analyzed via descriptive statistics. Non-parametric continuous data represented via median and interquartile range; nominal data represented as frequency and percentage.  
 
Results:  
In this study, 36 patients met inclusion criteria and were included. 
During the study period, eight patients (22.2%) experienced at least one adverse drug reaction. The most prevalent adverse drug reaction was transaminitis which was present in 5/15 (33.3%) patients. No patients were diagnosed with kernicterus, but one patient (2.8%) did experience hyperbilirubinemia that resolved after four days of phototherapy.  
Two patients (5.6%) discontinued SMX-TMP prior to the intended stop date due to an intolerable adverse drug reaction. One patient was noted to have had an apparent allergic reaction, and the other patient experienced hyponatremia and acute kidney injury.  
 
Conclusion:  
SMX-TMP was relatively well tolerated in this study. Few patients discontinued treatment due to adverse effects, most patients did not experience an adverse drug reaction, and no serious side effects (like kernicterus) were observed.  

Self-Assessment Question:
What was the most common adverse drug reaction observed in this study? 
A) Kernicterus
B) Hyperbilirubinemia 
C) Transaminitis 
D) AKI 
 

Title: Aprepitant and fosaprepitant use and the effect on time to discharge in cyclic vomiting syndrome patients 
Authors: Abigail Christman, PharmD; Joel Wagner, PharmD 
Learning Objective: Audience members will be able to describe how use of aprepitant and fosapreptiant effects other antiemetic use for patients with cyclic vomiting syndrome 
 
Overview/Background:
Aprepitant and fosaprepitant are options for abortive therapy in patients with cyclic vomiting syndrome (CVS). The goal of this project was to assess how the updated restriction criteria affected the length of stay of patients with CVS. 
 
Methods:
This is a single-center, retrospective chart review of patients on a pediatric service who received neurokinin-1 receptor antagonists (NK-1 RA) for CVS from 1/1/2022-9/15/2025. Patients who received these medications for chemotherapy-induced nausea were excluded. Patients included had a comparator admission for CVS without receiving NK-1 RA. For patients that did not have a comparator admission, the same characteristics were pulled and assessed separately. A paired t-test was used to analyze the primary outcome. Other outcomes were assessed using descriptive statistics. The primary outcome was hospital length of stay when patients received a NK-1 RA compared to when they did not receive one. Secondary outcomes included time from admission to NK-1 RA use, time from NK-1 RA to discharge, number of agents used prior to NK-1 RA use, and readmissions for CVS within 30 days from discharge. 
  
Results:
There were 13 people that met inclusion criteria for the paired cohort. For baseline characteristics the patients were a majority female (77%), and mostly white (69.2%) with the median age in the NK-1 RA group being 15 years and the median age where no NK-1 RA was given was 14 years The average length of stay for the admissions where patients did not receive an NK-1 RA agent was 4.23 days, and for admissions where they did receive a NK-1 RA agent, the average length of stay was 7 days (p=0.279). Admissions where patients did not receive an NK-1 RA had fewer total antiemetics administrations on average compared to admissions where NK-1 RAs were used (21 vs. 29).  
 
Conclusion:
There was no statistically significant difference in the length of stay in the admissions where an NK-1 RA was given compared to admissions where an NK-1 RA was not given. Patients given an NK-1 RA required more anti-emetics. While length of stay results were not statistically significant, illness severity and being refractory to other treatment modalities may have influenced outcomes. This information will be used to review restriction criteria for the use of NK-1 RA agents in this population.  
 
Self-Assessment Question: 
Do NK-1 RA agents have a place in management of cyclic vomiting syndrome? 

Authors:
Jasmine Ramirez, PharmD1; Kayla Marks, PharmD, BCPPS1; Iman Moawad, PharmD, BCPPS1; Alexandra Sharpe, PharmD, BCPS, BCPPS1; Adele Ye, PharmD1; Chadi El Saleeby, MD2
1Department of Pharmacy, Massachusetts General Hospital, Boston, MA
2Harvard Medical School, Boston, MA

Background: 
Evaluate adherence, safety, and target goal attainment (AUC0-24/MIC ratio between 400 and 600) of current institutional pediatric vancomycin protocol.

Learning Objective:
Evaluate outcomes associated with an institutional AUC/MIC based pediatric vancomycin dosing protocol.

Methods:
A retrospective chart review was conducted on pediatric patients (1 month-17 years) admitted to general pediatrics or pediatric intensive care unit and received vancomycin during 11/1/2024-11/1/2025 with levels measured. Patients with prior vancomycin intolerance, pre-existing renal dysfunction, or without levels measured were excluded. Initial vancomycin dosing was based on institutional pediatric protocol with a target AUC/MIC of 400-600mg*hr/L, assuming MIC <1. Collected patient data included age, sex, height, weight, and level of care. Collected vancomycin parameters included infectious indication, dose, and patient-specific pharmacokinetic data. Concomitant nephrotoxins and instances of nephrotoxicity were collected to assess safety. The primary outcome was the percentage of patients dosed by protocol achieving therapeutic AUC/MIC. The secondary outcome was safety.

Results:
A total of 86 patients were reviewed for eligibility and 76 patients met inclusion criteria. Of the patients included, 60 patients were dosed in compliance with institutional pediatric vancomycin dosing protocol. From these 60 patients, 53.3% of patients achieved an initial therapeutic AUC/MIC and 70% of patients reached therapeutic AUC/MIC prior to vancomycin discontinuation. One of these patients developed an acute kidney injury and one patient had a vancomycin infusion reaction. Children > 37.6 kg received a maximum dose of 750 mg every 6 hours per protocol. In this population subset, 87.5% of patients achieved therapeutic AUC/MIC at initial measurement compared to 40.9% of patients who were dosed according to weight.

Conclusion:
In the majority of patients, institutional dosing protocol was able to attain therapeutic AUC/MIC at first measurement. Areas for protocol improvement include initial dosing recommendations in patients who were dosed according to weight, consideration of a loading dose, and evaluation of using a single level to extract AUC/MIC from population kinetics. While the current protocol is safe, a larger study population is needed to determine specific dosing adjustments.

Title: Evaluation of an accelerated enteral sedation wean pathway in pediatric patients  

Authors: Emma Covington, PharmD; Steven Astrachan, PharmD, BCPPS; Kathlene DeGregory, PharmD, BCOP; Lynn McDaniel, MD; Michael McCullough, MD; Kira Dubester, MD; Naomi Howard CPNP; Christine Bryant, PharmD, BCPPS 

Learning Objective: After this presentation, the participant will be able to evaluate key interventions and describe how standardized documentation increases utilization of a risk-stratified pediatric sedation wean protocol. 

Background: Pediatric patients with prolonged sedative infusion exposure are at risk for iatrogenic withdrawal syndrome, increasing morbidity, and length of stay. This project aimed to increase utilization of an accelerated wean protocol to ≥75% from 58%. 

Methods: An interdisciplinary quality improvement initiative was conducted using the Plan–Do–Study–Act methodology. Diagnostic evaluation included retrospective chart review from October 2024 through September 2025, process mapping, fishbone analysis, and statistical process control charts to identify sources of variation. 
Interventions implemented in two phases in January 2026 and March 2026 targeted documentation, communication, and clinical decision support. Protocol criteria were broadened, a standardized pharmacist wean initiation note was implemented, and a pediatric intensive care unit (PICU) to floor handoff process was introduced.  
The primary outcome was the proportion of eligible patients initiated on the accelerated pathway. Process measures included risk stratification per protocol and pharmacist note utilization. Balancing measures assessed the expected length of wean compared to actual length of wean as a marker for reduced tolerability. 

Results: From phase one implementation through May 6, 2026, the proportion of patients initiated on the accelerated pathway was __ compared with a baseline of 58%. Pharmacist note utilization was 92% after four months. PICU handoff order utilization was at 0%. Completeness of documentation was assessed by ensuring optional fields were completed, which was 100% at four months. Balancing measures assessed length of wean, seen in one patient, and escalation of care, seen in no patients
. 
Conclusion: Standardizing handoff communication and documentation increased appropriate utilization of an accelerated sedation wean pathway without safety concerns. These interventions were feasible and may improve the reliability of pathway selection and support future outcome evaluation. 

Assessment question: Which is not a potential patient benefit to using an accelerated pediatric sedation wean protocol? 
a. Reduced PICU length of stay
b. Reduced ICU delirium
c. Increased WAT-1 scores
d. Reduced cumulative dose of sedative agents

Authors
Katherine Gordon, PharmD, Aubrie Mason, PharmD, BCPPS, Timothy Olson, MD, PhD, Hope DiTaranto, PharmD, Christopher Phillips, PharmD
Learning Objective
At the conclusion of this presentation participants will be able to describe romiplostim dosing patterns and clinical response in pediatric hematopoietic stem cell transplant patients with treatment-related thrombocytopenia.
Background/Objective
The objective of this study is to describe romiplostim dosing in pediatric hematopoietic stem cell transplant patients and characterize response, including time to platelet recovery, treatment failure, and adverse outcomes.
Methods
This descriptive retrospective cohort study included patients aged >1 year and <25 years who received romiplostim for post-hematopoietic stem cell transplant (HSCT) treatment-related thrombocytopenia while inpatient between May 31, 2018 and May 31, 2025. Data collected included demographics, romiplostim dosing, platelet counts, transfusions, safety events, and treatment failure. Outcomes were assessed from romiplostim initiation to discontinuation, with safety and treatment failure monitored for up to one year afterward. The primary endpoint of this study was the romiplostim dose required to achieve platelet response. Secondary endpoints included time to response, treatment failure, and safety outcomes. Descriptive statistics were used, and the primary endpoint was summarized as a distribution stratified by HSCT type.
Results
Eleven patients received romiplostim for post-HSCT treatment-related thrombocytopenia. Seven patients (63.6%) achieved response. Among responders, median starting dose was 3 (IQR 1.1 – 4) mcg/kg weekly, with median dose of 8 (IQR 4.5 – 10) mcg/kg weekly and median escalation of 0.5 (IQR 0.4 – 0.9) mcg/kg/week. Median time to response was 6 (IQR 5.6 – 6.5) weeks. Median platelet count increased from 19 (IQR 18.5 – 27) to 69.6 (IQR 57 – 99.4). One patient experienced a safety event of thrombocytosis.
Conclusion
Patients who responded to romiplostim post-HSCT required higher doses to achieve response compared to FDA approved indications. The dosing strategy generally represented a gradual increase in dose followed by discontinuation after observed clinical response. Despite higher dosing, treatment was well tolerated, supporting its potential role as a safe and effective option in this population.
Self Assessment Questions
True/False: In a single retrospective cohort study, post-HSCT patients required a higher romiplostim doses to achieve response and had a higher rate of adverse effects as compared to other indications.

Authors: Kayla Bey, PharmD; Anthony Vecchione, PharmD; Francesca Mernick, PharmD 

Background: 
Dexmedetomidine is a centrally acting alpha-2 agonist used for light to moderate sedation, with a lower risk of respiratory depression. Dexmedetomidine has also been shown to affect thermoregulation via central alpha-2 receptors. Adult studies have shown an association between dexmedetomidine and hyperthermia, with risk factors such as obesity and open-heart surgery. Pediatric data are limited, with one recent single-center study reporting fever incidence of 8.6% in PICU/NICU patients receiving dexmedetomidine. Understanding the incidence of fever in a broader pediatric cohort is important, as fever in critically ill children may trigger unnecessary infectious workups and antibiotic exposure. 

Learning Objective: 
Build upon the limited data on the incidence of fever in pediatric patients in the pediatric intensive care unit (PICU) receiving dexmedetomidine in a large academic medical center

Methods: 
This retrospective chart review included pediatric patients admitted to the PICU from April 1, 2022 to October 1, 2025 who received ≥6 hours of dexmedetomidine. Patients with fever prior to initiation or conditions affecting thermoregulation were excluded. The primary outcome was incidence of fever (≥38°C). Secondary outcomes included dexmedetomidine dosing and duration, time to fever onset, infectious workup, antibiotic initiation, and acetaminophen and steroid use. Continuous variables were compared using Wilcoxon rank-sum test and categorical variables using chi-square test.

Results:
Of 191 included patients, 36 (18.8%) developed fever. Median time to fever onset was 41 hours. Patients with fever had higher maximum dexmedetomidine rates (1.6 vs 1.0 mcg/kg/hr, p<0.001) and longer duration of therapy (144 vs 24 hours, p<0.001). No differences were observed in age, weight, or BMI. Among febrile patients, 27.8% underwent infectious workup and received antibiotics.

Conclusion:
Dexmedetomidine-associated fever occurred in nearly one-fifth of pediatric patients and was associated with higher doses and longer durations of therapy. Recognition of this association may reduce unnecessary infectious evaluations and antimicrobial use.

Authors: Charlotte Spry, PharmD; Liz Remizowski, PharmD; Caroline Liang, PharmD, BCPS, BCPPS; Bethany Chalk, PharmD, BCPPS; Kelsey Foster, PharmD, BCPPS; Erica Prochaska, MD, MHS; Kartikeya Makker, MBBS; Alice Hsu, PharmD, BCIDP 
 
Objective: Describe the adequacy of NeoFax empiric vancomycin dosing regimens in achieving goal troughs in neonatal patients. 
 
Self-Assessment Question: Based on the results of this study, which of these statements is true regarding NeoFax empiric vancomycin dosing regimens in neonates? 
a. NeoFax empiric dosing fails to achieve therapeutic trough levels 
b. NeoFax empiric dosing achieves therapeutic trough levels 
c. NeoFax empiric dosing achieves supratherapeutic trough levels 
d. Vancomycin is not indicated in neonates 
 
Background: Vancomycin is often used in the neonatal intensive care unit (NICU) for late onset sepsis, occurring after day 7 of life. The objective of this study is to determine if empiric NeoFax vancomycin dosing achieves goal trough levels in NICU patients.  
 
Methods: We conducted a retrospective cohort study of patients admitted to two NICUs who received ≥ 24 hours of IV vancomycin with a steady state trough. Patients initiated on non-NeoFax empiric dosing or requiring extracorporeal membrane oxygenation or renal replacement therapy were excluded. Demographic data, vancomycin dosing, and steady state trough levels were collected manually from the electronic medical record. Incidence of acute kidney injury (AKI) while on vancomycin was also evaluated. Descriptive statistics were performed, including medians with interquartile range (IQR) and percentages. Chi Square and Kruskal-Wallis tests were used for comparisons, as appropriate. All analyses were performed in Stata version 18. 
 
Results: Of the 437 patients screened, 200 met inclusion criteria. Median post-menstrual age and post-natal age were 36.6 weeks (IQR 32.2-39.8 weeks) and 3.5 weeks (IQR 1.9-7 weeks), respectively. Overall, 161 (80.5%) patients were subtherapeutic with a median trough level of 7.9 mcg/mL (IQR 5.9-10.2 mcg/mL). Of patients targeting a trough of 10-14 mcg/mL, 29 (18.8%) were therapeutic and 121 (79%) were subtherapeutic, with a median trough level of 7.4 mcg/mL (IQR 5.8-9.6 mcg/mL). Of patients targeting troughs 14-17 mcg/mL, 6 (13%) were therapeutic and 40 (87%) were subtherapeutic, with a median trough of 9.7 mcg/mL (IQR 7.7-11.6 mcg/mL). AKI occurred in 13 (6.7%) patients. 
 
Conclusion: Empiric NeoFax dosing is inadequate in achieving target troughs in most NICU patients. More aggressive empiric dosing should be further investigated.  

Intravenous versus subcutaneous enoxaparin for the treatment of venous thromboembolism in the pediatric population

Authors: Brandon Ho, PharmD; Kelsey Mueller, PharmD, BCPPS; Kelly Lunsford, PharmD; Colleen Druzgal, MD

Learning Objective: The audience will be able to compare the safety and efficacy of intravenous (IV) enoxaparin compared to subcutaneous (SC) enoxaparin for the treatment of venous thromboembolism (VTE) in pediatric patients.

Background/Objective: SC enoxaparin is a common agent for pediatric venous thromboembolism but can be limited by pharmacokinetic variability and injection-site complications. Data for IV enoxaparin are limited, though it is used in other health systems.

Methods: This retrospective cohort study included hospitalized pediatric patients (<18 years) treated for venous thromboembolism with IV or SC enoxaparin at the University of Virginia (UVA) Health Children’s Hospital. Patients were excluded if they received oral anticoagulation prior to enoxaparin initiation or were diagnosed and treated with enoxaparin for venous thromboembolism prior to their admission at UVA. The primary outcome was a composite of anticoagulation failure and bleeding events. Secondary outcomes included time to therapeutic anti-Xa levels, dosing requirements, and time in therapeutic range. Categorical variables were analyzed using chi-square or Fisher’s exact tests, and continuous variables using Mann–Whitney U tests.

Preliminary Results: A total of 119 patients were included (IV n=47, SC n=72). The primary outcome occurred in 23.4% of IV patients and 22.2% of SC patients (p=1). Differences in the composite outcome were driven primarily by higher rates of new VTE in the IV group (17% vs 4.2%, p=0.02), while rates of progression, recurrence, bleeding, and lack of radiologic response were similar. Initial dosing and achievement of therapeutic anti-Xa levels were similar between groups, but patients in the IV group had less time spent in therapeutic range compared to the SC group (67.4% vs 72.7%, p = 0.31).

Conclusion: IV enoxaparin demonstrated similar overall safety outcomes compared to SC administration in hospitalized pediatric patients. However, the IV group had higher rates of new VTE and more difficulty maintaining therapeutic anti-Xa levels, potentially related to greater baseline clinical complexity and variability in anticoagulation control in the IV group. Further studies are needed to better define optimal dosing and monitoring strategies for IV enoxaparin in pediatric patients.

Self-Assessment Question: Does IV enoxaparin provide superior maintenance of therapeutic anti-Xa levels compared to SC enoxaparin for the treatment of VTE in pediatric patients?

Title: Characterization of Pneumocystis jirovecci Pneumonia (PJP) prophylaxis strategies and breakthrough PJP during pediatric Hematopoietic Stem Cell Transplantation (HSCT)
Authors: Corinne Berkery, PharmD; Mikayla Mariano, PharmD; Jennifer Szwak, PharmD, BCPS, DPLA, FCCP; Blair Nuoffer, PharmD, BCPPS; Jessica White, PharmD, BCPPS; Amanda Memken, PharmD, BCPPS; Cambree Fillis, PharmD, BCOP
Learning Objective: Describe strategies for PJP prophylaxis in HSCT recipients
Background/Objective: This study aimed to evaluate current PJP prophylaxis strategies at Johns Hopkins Children’s Center (JHCC) and Johns Hopkins All Children's Hospital (JHACH) by describing the use, efficacy, and safety of PJP prophylaxis strategies pre- and post-HSCT.
Methods: This was a single center, multisite, retrospective, observational, cohort study including patients under 25 years of age who underwent allogeneic HSCT and received PJP prophylaxis at JHCC and JHACH between 01/01/2021 and 10/31/2025. Patients were excluded if they underwent autologous transplant or had incomplete medical records precluding outcome assessment. Baseline characteristics were collected including age, sex, indication for transplant, conditioning intensity, donor type, graft source, and graft-versus-host-disease prophylaxis strategy post-transplant. Outcome data were collected from day -10 through day +180. Descriptive statistics were used to summarize data. Time to engraftment between sulfamethoxazole-trimethoprim (TMP-SMX) and pentamidine was compared with a Mann-Whitney U test using STATA.
Results: Of 305 transplants reviewed, 160 were included. Prior to HSCT, 87 (54%) received TMP-SMX prophylaxis and 73 (46%) received pentamidine (intravenous or inhaled). Pentamidine was the predominant prophylactic agent utilized post-HSCT, with 145 (90%) of transplants initially receiving pentamidine and 7 (4%) TMP-SMX. Most transplants (70%) changed agents during the post-HSCT period. One patient (0.6%) had a proven PJP infection on day +17 post-HSCT. There was no difference in median time to platelet engraftment with pre-HSCT pentamidine compared to TMP-SMX (28 vs. 29 days, p=0.59). The median time to neutrophil engraftment was shorter for patients receiving pre-HSCT pentamidine compared to TMP-SMX (16 vs. 17 days, p=0.04).
Conclusions: A low incidence of breakthrough PJP (<1%) was observed among patients receiving PJP prophylaxis. The variability in strategies across sites within a single health system highlighted an opportunity to standardize pre- and post-HSCT PJP prophylaxis practices.
Self-Assessment Question: If a patient has severe thrombocytopenia post-HSCT, which agent would most likely be used for PJP prophylaxis?
a. TMP-SMX
b. Pentamidine
c. Dapsone
d. Atovaquone

Learning Objective: Audience members will be able to identify the importance of inventory optimization in a hospital pharmacy setting. 
Background/Objective: To address inefficient automated dispensing cabinets (ADCS) workflow, this project analyzes retrospective usage to develop and optimized inventory strategy for operating room (OR) Pyxis cabinets that balances availability and cost.  
Methods: A retrospective analysis was conducted during a period of stable case volume (May-August 2025) across 20 OR ADCs to evaluate baseline usage patterns for 60 medications. The study evaluated current inventory efficiency by quantifying key performance indicators, specifically the rate of stockouts, total refill volume, and the cumulative cost of expired medications.  
Results: TBD 
The retrospective analysis of 20 ADCs revealed a baseline stockout rate of [X]% across the 60 studied medications, necessitating [Y] manual refills. This inefficiency contributed to an annualized estimated waste of $[Z] in expired inventory. Preliminary modeling suggests that implementing the proposed Economic Order Quantity (EOQ) framework could reduce carrying costs by approximately [A]% and decrease stockout frequency by [B]% compared to the current static par level method. 
Conclusion: TBD