PSHP 2026 Residency Conference

Purpose: Evaluate the overall impact of transitioning from a weight-based to non-weight-based fentanyl infusion dosing strategy in critically ill, mechanically ventilated patients in the critical care unit.
Methods: Through a retrospective electronic medical record chart review, adult patients who were admitted to the critical care unit, were mechanically ventilated and receiving a fentanyl infusion were identified for inclusion. Exclusion criteria included patients not admitted to the critical care unit, not mechanically ventilated, did not receive a fentanyl infusion for more than 24 hours, received concomitant neuromuscular blockers and patients who underwent targeted temperature management. The patient population was characterized using descriptive statistics. Students’ T-test or Mann-Whitney U tests were used for continuous variables, and Chi-squared was used to measure the association between categorical variables. Power calculation determined that 100 patients would be included to evaluate study outcomes.
Results: One hundred patients were included in the final analysis. For daily fentanyl dose, there was no statistically significant difference between pre- and post-implementation groups (p-value: 0.391). There was a statistically significant difference between groups for the maximum fentanyl infusion dose (p-value = 0.007). The subset of patients with BMI 30 or greater showed no difference between groups for daily fentanyl dose (p-value: 0.411). The difference between subset groups for maximum fentanyl infusion dose was statistically significant (p-value: 0.006). For length of stay in the critical care unit and total time spent on mechanical ventilation, there was not a statistically significant difference between groups (p-value: 0.139).
Conclusion: Implementation of a non-weight-based fentanyl infusion dosing strategy did not significantly reduce mean daily fentanyl dose compared to weight-based dosing. However, it significantly reduced maximum infusion doses, including in patients with a BMI ≥30. No significant differences were observed in ICU length of stay or duration of mechanical ventilation. These findings suggest non-weight-based dosing may reduce peak opioid exposure without compromising clinical outcomes.

Purpose: This study compared the trends of total daily dose (TDD) of sedation and paralytic medications in intubated pediatric patients prior to and after the implementation of the State Behavioral Scale (SBS) and Cornell Assessment of Pediatric Delirium (CAPD). 


Methods: This was an IRB-exempt single center retrospective chart review taking place during three different time periods in the pediatric intensive care unit (PICU) at Penn State Health Golisano Children’s Hospital (PSHGCH). Study periods were defined as follows: Stage 1, (January 1, 2017-December 31, 2018) prior to the implementation of both SBS and CAPD; Stage 2 (March 5, 2024-January 31, 2025), following SBS but prior to CAPD implementation; and Stage 3 (February 1, 2025-August 31, 2025), after implementation of both SBS and CAPD. In each cohort, TDD was calculated for all sedative, paralytic, and delirium agents. Daily sedation burden was calculated using the Pediatric Normalized sedation Index (PNSI), which provides an objective measure of sedation burden for the patient. The primary outcome of this study is to compare sedative and paralytic use before and after the implementation of SBS and CAPD. Data analysis was done using the Kruskal-Wallis test. 


Results: 526 patients were screened with the inclusion of 134 patients in the final analysis. Baseline characteristics were well balanced across groups, with no meaningful differences observed except length of intubation (p = 0.0496).  PNSI differed overall across all time points combined and changed differently overtime with an apparent increase in sedation use during Stage 2 and subsequent decrease in sedation use during Stage 3 (Group p <0.001; Interaction p <0.0010). PNSI on each individual day was not statistically significant except for day 1 (p < 0.001). Vecuronium use differed across all time points combined but did not distinctly change over time (Group p < 0.001; Interaction p = 0.1008). 


Conclusion: Sedation use increased during Stage 2 following implementation of SBS scoring and subsequently decreased during Stage 3 with the implementation of CAPD scoring. Trends in paralytic use remained inconclusive and limited clinical interpretation. Larger future studies are needed to better evaluate these patterns and determine the clinically meaningful impact of SBS and CAPD on both sedation and paralytic use. 

PURPOSE: The purpose of this study is to evaluate the safety and efficacy of bivalirudin versus heparin as anticoagulation for patients receiving either VA or VV ECMO. 
 
METHODS: This single center, retrospective chart review evaluated patients at Temple University Hospital between June 1st, 2019 to June 30th, 2025 who were placed on either VA or VV ECMO and received anticoagulation with either heparin or bivalirudin for at least 72 hours. The primary composite endpoint for the efficacy of bivalirudin in the use of ECMO compared to heparin was the overall incidence of thrombosis occurrences including venous and arterial thromboembolism and/or circuit related thrombotic event occurring after anticoagulation initiation. Secondary outcomes included bleeding occurrences while on anticoagulation and ECMO and the average volume of blood products received. Data collection included patient demographics, baseline characteristics, and anticoagulant used while on ECMO. Demographic data was analyzed using descriptive statistics, categorical data was analyzed using Chi- square test, and continuous data was analyzed by Student T-test. 
 
RESULTS: A total of 78 patients were included: median age 59, 69% male, and 60% received VV ECMO. The incidence of thrombotic events was similar between heparin and bivalirudin (10.2% versus 12.5%, p = 0.754). More patients who received heparin experienced a major bleeding event compared to those who received bivalirudin (28.2% versus 2.6%, p < 0.001). Additional analysis is ongoing.
 
CONCLUSION: Patients receiving bivalirudin for systemic anticoagulation on extracorporeal membrane oxygenation did not have an increased incidence of thrombotic events and had a significantly lower incidence of major bleeding events compared to heparin.  

Purpose:
To evaluate the proportion of patients with spontaneous intracerebral hemorrhage (ICH) achieving institutional systolic blood pressure (SBP) targets within 60 minutes of head computed tomography (HCT).


Methods:
This retrospective cohort study included adult patients with spontaneous ICH admitted to entities within the University of Pennsylvania Health System between January 1, 2025, and November 30, 2025. Patients were stratified by presenting SBP (<220 mmHg vs >220 mmHg), corresponding to institutional protocol targets. For patients presenting with SBP greater than 220 mmHg, the initial goal is to reduce SBP to less than 180 mmHg within the first hour. For patients presenting with SBP between 180–220 mmHg, the target range is 130–150 mmHg. The  primary outcome was achievement of protocol-defined SBP target within 60 minutes of HCT confirmation. Secondary outcomes included antihypertensive medication regimen, time to target SBP, SBP variability during the first six hours after HCT , neurologic outcomes , incidence of hematoma expansion or ischemic stroke, mortality, and safety outcomes including hypotension and bradycardia. 


Results: 
A total of 39 patients met inclusion criteria (SBP <220 mmHg: n=23; SBP >220 mmHg: n=16). Achievement of target SBP within 60 minutes occurred more frequently in patients presenting with SBP > 220 mmHg (39.1% vs 93.8%, p<0.01).  Nicardipine was utilized in all patients and was initiated within 30 minutes of HCT confirmation in 69.6% and 75% of patients with SBP <220 mmHg and >220 mmHg, respectively. In-hospital mortality occurred in 8.7% of patients with SBP <220 mmHg and 6.3% with SBP >220 mmHg (p=1.00). The incidence of ischemic stroke was 8.7% versus 25.0%, respectively (p=0.21). Hypotension occurred in one patient (4.3%) in the SBP <220 mmHg group (p=1.00).  No  cases of bradycardia were observed.


Conclusion:
Patients with SBP >220 mmHg were more likely to achieve protocol-defined SBP targets within 60 minutes compared with those <220 mmHg. Despite rapid blood pressure reduction, rates of hypotension and bradycardia were low. These findings suggest that early SBP control in patients with moderately elevated SBP may reflect differences in clinical attention and management intensity, highlighting a potential need for more optimized titration strategies.

Purpose: To implement a pharmacist-driven protocol which allows for the step-down of IV ceftriaxone to PO antibiotics for hospitalized patients with uncomplicated and complicated urinary tract infections to help improve transition time.  
Methods: A prospective study will be conducted from February 23, 2026 to May 12, 2026, using data collected from EPIC. The included patients will be age 18 and older with a UTI diagnosis, presence of stones, obstruction, strictures, TURP, prostatitis, stents, associated bacteremia, indwelling urinary catheters, pregnancy and before/after genitourinary procedure. Patients will be excluded if they have asymptomatic bacteriuria, secondary diagnosis for another infection, renal abscess, or are immunocompromised.  
The primary endpoint is transition time from IV to PO antibiotics. Secondary endpoints include length of stay, 30-day UTI readmission rates, total length of therapy, antibiotic selection and dosing. The endpoints will be compared to a retrospective analysis from May 1, 2025, to June 30, 2025, to assess if a pharmacist-driven protocol allowed for a timely transition to oral antibiotics and/or a reduction in any of the secondary endpoints.
Results: TBD 
Conclusion: TBD 
IRB Approval: IRB approval is not required as this research is categorized as a process improvement project.  

Purpose: Despite structural dissimilarity between penicillins and piperacillin/tazobactam (P/T), the incidence of cross-reactivity is unknown. This project evaluated the incidence of P/T reaction in patients with documented β-lactam reactions.


Methods: This was a retrospective single-center cohort analysis evaluating patients with reported β-lactam reactions who received P/T from July 2022 to June 2025. Patients were included if they received at least one dose of P/T during this time and had a previously reported β-lactam reaction. Patients were excluded if they were less than 18 years old, the P/T order was not administered, or there was insufficient quality of data. The primary outcome was the compared incidence of P/T reactions between patients with documented penicillin class reactions versus patients with reactions to all other β-lactams and β-lactamase inhibitors. Secondary outcomes were the incidence of P/T reactions in the following subgroups: subclass of previous β-lactam reaction, previous reaction type classification, P/T duration, and number of previously reported reactions. Results were analyzed using a Chi-squared analysis and descriptive statistics.


Results: Of 183 patients screened for analysis, 164 were included. Previously reported β-lactam reactions were classified as IgE-mediated (30%), non-IgE-mediated (18%), adverse reactions (23%), and unknown (29%). There were 21 (13%) patients with multiple β-lactam allergies. Potential reaction to P/T occurred in 0/87 (0%) patients with penicillin class reactions and 1/77 (1.3%) patients with non-penicillin β-lactam reactions (p=0.286). The patient with a documented reaction to P/T had a history of developing hives to cefuroxime. The median [IQR] length of treatment for patients who received multiple doses in an encounter was 2 [1-3.5] days, with the most common reason for discontinuation being targeted antimicrobial therapy (47%). 


Conclusion: In patients labeled with a β-lactam reaction, there was minimal incidence of P/T reactions, with 1/164 patients (0.6%) experiencing a documented reaction. These results support the hypothesis that cross-reactivity would be low based on structural dissimilarity, including penicillin class allergies. Further research is warranted to further elucidate the safety of administering P/T in this patient population.

Purpose: 
The aim of this study was to evaluate the impact of albumin status on clinical and microbiological outcomes of patients treated with ertapenem or meropenem for ESBL-E bacteremia, and to identify factors associated with treatment failure.
 
Methods:
We conducted a dual-center, retrospective cohort study of adult patients admitted between October 1, 2022, and October 1, 2025, who received ertapenem or meropenem for the treatment of ESBL-E bacteremia (ceftriaxone-resistant Escherichia coli, Klebsiella spp. (non-aerogenes), or Proteus spp.). Patients were stratified by albumin status (L-Alb: serum albumin < 2.5 mg/dL or N-Alb: serum albumin ≥ 2.5 mg/dL) and carbapenem selection. The primary outcome was a composite of treatment failure: death, readmission for related infectious causes, recurrent infection, or absence of clinical improvement by day 14. Secondary outcomes included 30-day all-cause mortality and evaluation of clinical characteristics hypothesized to be associated with treatment failure. Categorical variables were compared using chi-square or Fisher’s exact tests. A multivariable logistic regression was performed to identify factors independently associated with outcomes.
 
Results: 
Among 203 patients with a median age of 63 years, 23.6% had L-Alb, and 49.8% were immunocompromised. Bacteremia was primarily caused by E. coli (57.6%) from urinary or intra-abdominal sources, and the 30-day all-cause mortality rate was 14.3%. The primary outcome occurred in 24.6% of the cohort. Treatment failure was higher in patients with L-Alb versus N-Alb (47.9% vs 17.4%, P < 0.01) and with ertapenem in relation to albumin status (42.3% vs 12.9%, P < 0.01), but not with meropenem (54.5% vs 35.5%, P = 0.17). On multivariable analysis, L‑Alb (OR 2.76, 95% CI [1.26-6.04]) and lack of source control (OR 4.45, 95% CI [1.77-11.22]) independently predicted treatment failure, while ertapenem did not appear to (OR 0.42, 95% CI [0.19–0.93]).
 
Conclusion: 
Our study presents medically complex patients with ESBL-E bacteremia not limited by infectious source. While prior literature cautions against ertapenem in patients who are critically ill and/or with L-Alb, our data suggests that poor ertapenem efficacy is multifactorial. Although failure rates were higher in patients with L-Alb receiving ertapenem, ertapenem did not appear to be associated with increased failure after adjusting for confounders.
 

Objective: The purpose of this study was to evaluate the impact of a pharmacist-driven antimicrobial stewardship (ASP) initiative using rapid diagnostic testing (RDT) on de-escalation of antipseudomonal antibiotic therapy for Enterobacterales bloodstream infections (BSIs).  
Methods: This was a multi-center, retrospective, comparative cohort study was approved by the institutional review board review (IRB) and included a sample of adult patients with Enterobacterales bacteremia who received empiric antipseudomonal therapy. Treatment was compared pre- and post- implementation of RDT. The primary outcome was time (hours) to de-escalation of antipseudomonal coverage. Secondary outcomes included days of antipseudomonal antibiotic therapy, 30-day mortality, and incidence of Clostridioides difficile infection (CDI). A subgroup analysis was also conducted to evaluate the use of anti-methicillin resistant Staphylococcus aureus (MRSA) therapy. Antimicrobial stewardship activities were also evaluated in the post-implementation group. 
Results: This study included 44 patients in the pre-implementation group and 60 patients in the post-implementation group. Baseline characteristics were comparable between both groups. The median time (hours) to de-escalation of antipseudomonal coverage for Enterobacterales bacteremia was found to be significantly lower in the post-implementation group (9.3 vs 50.5, p < 0.001). Median days of therapy was also found to be lower in the post-implementation group (2 vs 4 days, p < 0.001). The 30-day mortality rate, CDI events, and days of anti-MRSA therapy were not statistically different between groups. 
Conclusion: This study demonstrated that a pharmacist-driven antimicrobial stewardship initiative was successful in reducing time to targeted therapy in hospitalized patients receiving treatment for Enterobacterales bacteremia.

0.25 contact hour continuing education

0.25 contact hour continuing education

0.25 contact hour continuing education