PSHP 2026 Residency Conference

Purpose:
To evaluate early transition (at day 3 or less) compared to late transition (after day 3) of intravenous (IV) to oral (PO) antibiotics on clinical outcomes. 


Methods:
This study utilized retrospective chart review of patients treated for CAP within Lankenau Medical Center (LMC). Adult patients were included if they met CAP criteria published in the IDSA guidelines and received at least 3 days of antibiotic therapy. Patients were excluded if they did not meet criteria for transition to oral therapy in IDSA CAP guidelines, transferred from another inpatient facility, had concomitant infection treatment, or admitted to an intensive care unit on the day of antibiotic initiation. The primary outcome compared 30-day readmission rates between patients transitioned to PO before and after day 3 of antibiotics. Key secondary outcomes were compared between these groups and included 90-day all-cause mortality, hospital length of stay, total antibiotic days of treatment, and Clostridium difficile infection at day 90. 


Results:
676 patients were screened for meeting criteria, of which 50 met inclusion criteria. Six of these patients met early transition criterion, with 44 qualifying for late transition. Baseline characteristics across the two treatment groups were similar in Charlston Comorbidity Index and Pneumonia Severity Index scores. Thirty-day readmission occurred in 8 (18.2%) of the late transition group, with no readmissions in the early transition group. One patient within the late transition group did have mortality at 90 days, while no patients within the early transition group met this criterion. Both treatment groups had a median length of hospital stay of 5 days. 


Conclusion:
For patients meeting IDSA criteria, early transition to oral antibiotics in CAP patients was associated with decreased 30-day readmission rates as compared to late PO transition.

Purpose: Ideal timing of preoperative antibiotic administration in relation to incision time remains unclear. This study aims to evaluate optimal timing of preoperative antibiotic administration to mitigate the risk of surgical site infection (SSI).


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 between January 2022 and 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 rate by preoperative antibiotic administration time. Secondary outcomes included admission for SSI, hospital length of stay, readmission for SSI, and mortality at 30 and 90 days post-operation. SSIs were categorized based on National Healthcare Safety Network (NHSN) definitions.


Results: Cefazolin was the most frequent preoperative antibiotic administered (863 of 993 cases). Preoperative administration time was evaluated at 15-minute intervals, with time 0 being start of procedure. The SSI rate when cefazolin was administered before or at 45 minutes prior to procedure was significantly lower than the SSI rate when cefazolin was administered beyond 45 minutes (18.5% vs 44.4%, P = 0.005). The majority of patients presenting with a SSI were admitted for inpatient management (67.6%). In the subgroup analysis, cefazolin was associated with a significantly lower rate of SSIs compared to clindamycin (P = 0.013).


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


IRB approval: yes 

Purpose:
This study evaluates the impact of reduced-dose amikacin liposome inhalation suspension (ALIS) on treatment outcomes in patients with pulmonary nontuberculous mycobacteria (NTM) infections who may experience treatment intolerance. 


Methods:
This was a retrospective, descriptive study. Eligible patients started ALIS therapy from September 1, 2018-June 30, 2024, and filled ALIS through the health system specialty pharmacy. Patients must have completed at least 6 months of ALIS therapy by June 30, 2025. Data was sourced through the pharmacy software system, and data collection was conducted through chart review. Patient adherence was quantified by a percentage of days covered (PDC), calculated based on refill history. The primary outcome was prevalence of negative cultures with various dosing strategies. Secondary outcomes included the incidence of culture reconversion up to one year after the first negative culture conversion or at the end of the study period, new culture resistance, number of patients with reduced ALIS dosing strategies, reasons for ALIS dose adjustments, and total duration of ALIS treatment.  Descriptive statistics were used to report outcomes. 


Results:
30 patients were included in this study and 17 (56%) were considered adherent to daily dosing based on a PDC of >80%. Overall, 24 (80%) patients achieved culture conversion, with 12 of 17 patients in the >80% PDC group and 12 of 13 in the <80% PDC group. Median time to culture conversion was 178.5 (117-216.5) days. Median time to culture conversion in the >80% PDC group was 201 (105-247.25) days vs.146 (122.5-210.75) days in the <80% PDC group. There were 12 (20%) patients with culture reconversion, with 6 of 17 patients in the >80% PDC group and 6 of 13 in the <80% PDC group. One patient (3.3%) developed new resistance to amikacin. There were several reasons for dose adjustment, with the most frequent reason being adverse effects. 


Conclusion:
Dose adjustments of ALIS did not appear to influence the rate of culture conversion in this study. There was a limited impact on resistance or duration of ALIS treatment. This suggests dose adjustment strategies may be an option for patients with adverse effects; however, further research is needed.

Purpose: Given the opportunity to optimize micafungin therapy in obese patients, our institution established a new protocol that recommends high doses for patients > 125 kg. We aimed to evaluate the outcomes associated with this new protocol.
 
Methods: This is a retrospective cohort study of patients at Thomas Jefferson University Hospital Inc locations from December 2024 to March 2026. Patients were included if they were 18 years or older, had documented invasive candidiasis, and received micafungin for 3 or more days. Patients were excluded if they had a concomitant infection within 7 days, were given empiric combination antifungal therapy, or had Candida species isolated from the genitourinary tract. Outcomes will be compared between patients weighing ≤ 125kg, patients weighing > 125kg on standard dose micafungin, and patients weighing > 125kg on high dose micafungin. The primary outcome is a composite of all–cause 90-day mortality, microbiologic and clinical cure, and incidence of recurrent infections within 30 days. The secondary outcomes are 30-day infection related readmission, duration of micafungin treatment, hospital and ICU length of stay and duration of candidemia.
 
Results: A total of 318 positive Candida cultures were identified and of those, 271 patients were removed to meet the exclusion criteria. Therefore, the study cohort included a total of 42 patients with 40 patients in the ≤ 125kg group, 1 patient in the > 125kg with standard micafungin dose group, and 1 patient in the > 125kg with high micafungin dose group. No difference was seen with the primary composite outcome between the cohorts (p=0.448). Due to low enrollment, exploratory analysis was performed utilizing binomial linear regression. When including mg/kg dosing as a continuous variable and analyzed it with other impactful and confounding variables, we did not find that it added significantly to the model. 
 
Conclusion: Our results from a very limited data set suggest that increased micafungin dosing in obese patients was not associated with improved clinical outcomes for invasive candidiasis. Exploratory analysis did not suggest that higher micafungin dosing (measured in mg/kg) provided additional benefit. Our institution will continue to collect data, in hopes of generating a greater sample size. Larger studies are required to confirm these results. 

Abstract Title: Evaluation of Guideline-Recommended Weight-Based Initial Vancomycin Dosing in Septic Patients and the Effects on Therapeutic Level Achievement and Clinical Outcomes
Purpose: This study was designed to evaluate guideline-recommended weight-based initial vancomycin dosing of 25 mg/kg in septic patients and the effects on therapeutic level achievement and clinical outcomes.  
Methods: Institutional Review Board approval was obtained for this retrospective observational chart review. Patients were identified based on the order set utilized by providers for vancomycin loading dose. The order set used prior to September 2023 allowed providers to order a maximum loading dose of 1,500 mg, while the new sepsis order set guides providers to order 25 mg/kg loading doses with a maximum dose of 3,000 mg. Data was collected from March 1^st 2023, through March 31^st, 2025. The primary outcome is to determine if sufficient loading doses of vancomycin in septic patients result in faster achievement of therapeutic levels. Secondary outcomes include the rate of patients who experienced nephrotoxicity, time to administration of loading doses, length of stay, 30-day mortality, critical care admission, and the rate of MRSA bacteremia. Data analysis was completed with descriptive statistics, Wilcoxon Sum Rank test and Chi-squared test. 
Results: Initial vancomycin doses of 25 mg/kg, based on total body weight, in septic patients results in faster therapeutic achievement (p-value 0.000004) and lower rates of acute kidney injuries (p-value 0.005). The time from order to administration of initial vancomycin doses in the post-implementation group was about 25 minutes faster than the pre-implementation group and was almost one day shorter for the average length of stay compared to the pre-implementation group. In the pre-implementation group, the average loading dose was 15.5 (SD of 3.1) and the average AUC was 365.3 mg/h/L (SD of 122.6). In the post-implementation group, the average loading dose was 20.1 (SD of 4.4) and the average AUC was 419.9 (SD of 95.2).
Conclusion: Increased initial vancomycin doses resulted in faster therapeutic achievement and lower rates of acute kidney injury. There were no statistically significant differences between 30-day mortality, admission to critical care unit, MRSA bacteremia, time from order to administration and length of stay. Results support updating non-sepsis vancomycin order sets to increase the initial dose, as well as promoting batching larger vancomycin doses. 
Authorship: Paige de Fremery, PharmD; Miranda Cason, PharmD, BCPS; Troy Albrecht, PharmD, BCPS, BCIDP

Purpose:  
The purpose of this study is to evaluate the impact of prophylactic anti-Xa monitoring on rates of venous thromboembolism (VTE) events and bleeding in trauma patients at a level one trauma center.  
 
 
Methods:  
This retrospective cohort study includes patients admitted to the trauma surgery service from January 2019 – July 2025 treated with enoxaparin for VTE prophylaxis. Exclusion criteria includes patients who spent 48 hours or more at a referring facility before transfer or an anti-Xa level collected before 3.5 hours of after 6.5 hours from last enoxaparin dose. Patients were identified via an Enterprise Information Management report, data was extracted from the electronic health record using REDCap, and statistical analysis was completed using Microsoft Excel. The primary outcome is rate of thromboembolic events, and secondary outcomes include rates of bleeding, units of red blood cells transfused, ICU and hospital length of stay (LOS). Categorical data is compared using a chi-squared test, and continuous data is reported using descriptive statistics. The study is IRB exempt by the institutional review board at the study site.  
 
Results:  
A total of 196 patients are included in the study; 91 received anti-Xa monitoring and 105 patients did not. No statistically significant differences in rates of VTE events were observed between patients who received anti-Xa monitoring compared with those who did not (9.9% vs 7.6%, p-value 0.573). Rates of bleeding were higher in the anti-Xa monitoring group (44.0% vs 26.7%, p-value 0.01). Patients who received anti-Xa monitoring were more likely to have missed doses of enoxaparin (56.0% vs 41.0% p-value 0.03) and had a longer median ICU LOS (13.6 days vs 6.3 days). In patients receiving anti-Xa monitoring, 48/91 (52.7%) patients had an initial anti-Xa within the goal range, and only 3/91 (2.2%) had an anti-Xa above the goal range.  
 
 
 
Conclusion: 
Anti-Xa monitoring did not result in a difference in VTE events and was associated with higher bleeding rates. However, the anti-xa monitoring group had more missed doses of enoxaparin and longer ICU length of stay, which are risk factors for VTE events. This suggests that patients who received anti-xa monitoring likely had a greater severity of illness, leading to higher rates or bleeding, despite not having supratherapeutic anti-xa levels.  

PURPOSE: This study evaluates the incidence of bradycardia following dexmedetomidine initiation in critically ill patients and identifies clinical predictors and dosing patterns to inform monitoring and optimize sedation practices.
METHODS: This retrospective chart review included critically ill adult patients who received a dexmedetomidine infusion for greater than 2 hours admitted to a non-cardiac intensive care unit (ICU) from November 1st, 2024 to November 1st, 2025. The primary outcome was the incidence of bradycardia defined as less than 60 beats per minute (bpm) following dexmedetomidine initiation. Secondary outcomes included incidence of severe bradycardia (less than 40 bpm or requiring clinical action), incidence of hypotension, time to first bradycardic event, dose and duration of infusion, liver function on ICU admission, body mass index (BMI) at time of infusion initiation, and concomitant use of vasoactive or rate-controlling medications. Descriptive statistics were used to summarize primary and secondary outcomes, and a binary logistic regression was performed as an exploratory analysis to identify predictors of bradycardia.
RESULTS: Seventy patients were included, with bradycardia occurring in 25 patients (35.7%). Severe bradycardia occurred in 2 patients (2.9%). Median time to first bradycardic event was 6.33 hours [2.93, 10.45]. Median infusion duration was 28.1 hours [14.6, 72], and mean infusion rate was 0.99 ± 0.48 mcg/kg/hr. Hypotension occurred in 41 patients (58.6%), and vasopressor therapy was continued or initiated in a subset of patients during infusion. In a binary logistic regression, higher heart rate on hospital admission was associated with increased odds of bradycardia [p=0.013, (OR 1.046, 95% CI 1.010-1.084)], while higher heart rate at dexmedetomidine initiation was associated with decreased odds of bradycardia [p=0.004 (OR 0.936, 95% CI 0.896-0.979)].
CONCLUSION: Bradycardia occurred in over one-third of critically ill patients receiving dexmedetomidine. Baseline heart rate predicted bradycardia risk, with effects varying based on when it was measured, as higher heart rate on hospital admission increased risk while higher heart rate at dexmedetomidine initiation was associated with lower risk. These findings highlight the need for patient-specific assessment and close monitoring during therapy.
IRB Approval: iRISID-2026-0188

0.25 contact hour continuing education

0.25 contact hour continuing education

0.25 contact hour continuing education