To evaluate the potential sources and current screening strategies for the multidrug-resistant fungal pathogen Candida auris in the US Military Health System (MHS).

Utilizing the Multidrug-Resistant Organism Repository and Surveillance Network (MRSN), 6 instances of C. auris colonization or infection were identified within the MHS in 2024. Relevant medical and social history, drug susceptibilities, and next-generation genetic sequencing were obtained from MRSN and the electronic medical record. Hospital screening protocols for C. auris were reviewed in the affected facilities.

One case of C. auris infection and 5 cases of C. auris colonization in 2024 were identified in the MHS. Only 1 case of colonization was likely related to international travel; 5 patients had no recent travel history before infection or colonization. One patient was an active duty service member. Prior hospitalizations and infections were the most common risk factors present in each case. Two isolates had antimicrobial susceptibilities analyzed, both of which suggested resistance to fluconazole. Two of the 3 facilities had C. auris screening protocols in place to screen select individuals with risk factors; however, only 1 of the 6 cases presented was identified through these screening protocols. No cases of nosocomial transmission were found.

C. auris remains a formidable threat to the MHS, with 6 cases identified in 3 treatment facilities, with 2 isolates demonstrating resistance to azoles. Screening protocols should reflect the domestic and international threats of this pathogen.

This paper describes a health-system’s experience incorporating Standardized Antimicrobial Administration Ratio (SAAR) data to optimize the existing antimicrobial use module within the electronic health record. We describe the design and implementation via a standard operating procedure (SOP), which incorporates SAAR and the optimized dashboards into the health-system’s antimicrobial stewardship program.

This is a descriptive study outlining our process of optimizing the electronic health records default antimicrobial use dashboard into a dual-purpose dashboard, SAAR and Antimicrobial Use (AU) dashboard, to be used across a health-system.

10-hospital health-system

For adult and pediatric populations, a pre-populated dashboard was created for each SAAR antimicrobial category using the existing EHR application. For adult, pediatric, and neonatal populations, improvements were made to visualize AU data in the dashboards. We created the framework for a standardized metric for our health-system’s antimicrobial stewardship program (ASP). An SOP was developed to establish an expectation for SAAR data analysis at the site level of our health-system’s ASP. The dashboards and SOP were created to evolve with the AUR protocol and health-system.

Pre-populated dashboards for adult and pediatric SAAR antimicrobial categories are configurable within existing electronic health-records, requiring minimal manipulation from the user to view which antimicrobials are driving a location’s SAAR.

In anticipation of required AUR reporting, other health-systems using the same EHR can utilize this approach to integrate the SAAR into their health-system’s antimicrobial stewardship programs. Collaboration between antimicrobial stewardship clinicians, pharmacist information technology (IT) analysts and infection preventionists are essential to accomplish this endeavor.

Invasive candidiasis including candidemia is a common healthcare-associated infections with significant morbidity and mortality. The USA does not have mandatory national surveillance for mucocutaneous or invasive candidiasis which complicates estimation of epidemiology and outcomes. The aim of this project was to describe the epidemiology, mortality, and Candida-associated hospital readmissions in hospitalized patients with Candida species infections.

This secondary database analysis used clinical microbiology data from adults hospitalized at three large health systems (25-hospitals) in the Greater Houston area totaling over 1.6 million hospitalization days per year from 2018 to 2023. Proportion and rates of Candida cultures per 10,000 hospitalization days were calculated. Risk factors for mortality and Candida-associated readmissions were assessed by multivariable logistic regression.

Within the study period, 7514 hospitalized patients aged 64 ± 16 years (mean± standard deviation (SD)) with 10,183 unique Candida cultures were identified. Majority of Candida cultures were nosocomial (59%) with wide variability in mean time to positive culture (9 ± 44 days) after admission. Candida specimens were from blood (32%), abdomen (29%), or mucocutaneous (24%) cultures and most commonly C. albicans (44%) or C. glabrata (21%). C. auris increased significantly from 2% of cultures from 2018–20 to 5% in 2021–23 (p < 0.0001). Length of hospital stay was 21 ± 34 days and inpatient mortality was 17%. Multivariable analyses identified hospitalization variables and Candida species predictive of inpatient all-cause mortality and Candida-associated readmissions after initial hospitalization.

These analyses highlight the significant burden of candidiasis and the emergence of new strains, including C. auris. Ongoing surveillance can refine burden estimates and assess the impact of stewardship and infection control interventions.

To describe the screening practice of nasal methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) among nine health organizations in Kentucky.

The Kentucky Antimicrobial Stewardship Innovation Consortium (KASIC) invited its Advisory Board members to share their nasal MRSA PCR protocols and guidelines. The documents were examined to highlight institutional similarities and differences.

Nine health systems, including both community hospitals and academic medical centers, responded to the KASIC request. Most systems with nasal MRSA PCR testing capacity had established protocols or guidelines to support its appropriate use. All institutions recommended nasal MRSA PCR for pneumonia indications while three organizations also used it for non-pneumonia indications. None of these institutions permitted pharmacists to discontinue anti-MRSA antibiotics per protocol.

This study provides the first statewide overview of nasal MRSA PCR screening practices, offering stewardship programs a framework to customize their own protocols and guidelines.

Burn injuries result in loss of skin barrier and altered immune responses that in turn make patients especially vulnerable to healthcare-associated infections. Despite prolonged exposures of these patients to hospital environments, burn-specific infection prevention strategies are understudied. We present a research agenda identifying key research gaps and organizing them into priority areas to guide future investigations in this high-risk population.

Members of the Society for Healthcare Epidemiology of America (SHEA) Burn Infection Prevention and Control Special Interest Group and the American Burn Association (ABA) collaborated to develop this research agenda, combining expertise in infection prevention, antimicrobial stewardship, and burn care.

We identified five priority areas: (1) improving surveillance and epidemiologic data on burn infections; (2) better understanding of microbiology, including biofilms and the microbiome; (3) evaluating wound healing strategies; (4) refining infection prevention and control practices unique to burn units; and (5) building burn patient specific risk assessment and predictive models. The agenda highlights the need for standardized definitions and shared data platforms. It calls for evaluation of practical strategies for infection prevention, stewardship, and environmental control.

This research agenda intends to help guide future studies aimed at furthering knowledge and improving outcomes in burn care.

To determine the local applicability of 2021 American Academy for the Study of Liver Diseases spontaneous bacterial peritonitis (SBP) treatment guidelines by evaluating the microbiology and clinical outcomes of SBP cases in an academic health system.

Retrospective cohort study.

Five-hospital academic health system.

Hospitalized adult patients with SBP.

This study involved 2 components. First, patients meeting inclusion criteria with peritoneal fluid cultures positive for a pathogen were included in the culture-positive group. Antibiotic susceptibilities were analyzed for these patients. Second, remaining culture-negative patients were randomly selected and sequentially evaluated until the culture-negative and culture-positive groups were approximately the same size. Clinical data for all patients were evaluated based on empiric antibiotics received.

Forty-nine patients with culture-positive SBP and 48 patients with culture-negative SBP were included. Eight (16%) positive cultures contained TGC-nonsusceptible organisms. Patients receiving empiric third-generation cephalosporin (TGC) monotherapy had similar clinical outcomes as patients receiving empiric broad-spectrum therapy, including similar 30-day mortality (36% vs 38%; P = 1.00), 90-day mortality (55% vs 55%; P = 1.00), and median duration of hospitalization (6.5 d vs 8 d; P = .25). ICU admission, recent hospitalization, and nosocomial infection were not associated with TGC-nonsusceptible pathogen isolation in a univariate logistic regression analysis.

Within our health system, 16% of isolates in culture-positive SBP patients were nonsusceptible to TGCs. No statistically significant difference was detected in clinical outcomes in patients receiving TGC or broader-spectrum antimicrobial therapy.

To evaluate the efficacy of the Abbott ID NOW system in detecting COVID-19 using different specimen collection methods, emphasizing diagnostic accuracy and patient comfort.

Three cohorts were analyzed, including two using the nasopharyngeal (NP) swab technique and one utilizing the swish-and-gargle (SG) method. Positive percent agreement (PPA), negative percent agreement (NPA), and cycle threshold (Ct) values were assessed to determine the system’s performance.

The PPA for the NP swab cohorts averaged around 70%, while the SG cohort exhibited a higher PPA of 80%. All cohorts maintained high NPAs, close to 100%. The SG method significantly reduced false negatives, especially at lower Ct values, indicative of elevated levels of viral RNA. Additionally, the NP swab method, often uncomfortable, posed challenges in repeated testing scenarios, particularly among healthcare workers.

While the Abbott ID NOW system demonstrates reliable COVID-19 detection, the SG method emerges as a superior collection technique to NP swabs, offering enhanced diagnostic accuracy and improved comfort for test takers. This study underscores the importance of selecting appropriate collection methods to ensure accurate and efficient COVID-19 testing.

Despite concerns regarding toxicity and antimicrobial resistance, clindamycin prescriptions have remained significant at a large military healthcare system. This study evaluates patient and prescriber factors associated with outpatient clindamycin prescriptions.

This study evaluated clindamycin prescriptions filled between January and December 2023 at outpatient pharmacies in a large military healthcare system.

During the study period there were 1046 outpatients prescriptions for clindamycin among 972 adult and pediatric patients.

The cohort was predominately female (576, 55.1%) with a median age 48 [IQR 27.5–66]. The clinics with the most prescriptions were the emergency department (45.4%), primary care (23.6%), and surgical clinics (14.9%). While there were 533 prescribers, the ten highest writers of clindamycin accounted for 18.1% of all prescriptions. Beta-lactam allergy (38.5% vs. 16.0%, p ≤ 0.00001) was more common in patients with a dental indication and less common in those with a skin and soft tissue infection (51.3% vs. 23.3%, p ≤ 0.00001).

Despite local guidelines, clindamycin was still frequently used for a variety of indications in a large military healthcare system with high clindamycin resistance rates. Additionally, a small number of providers were found to be responsible for a disproportionate number of clindamycin prescriptions, highlighting potential targets for intervention for future antimicrobial stewardship interventions.

Limited data regarding predictors of antibiotic prescription for acute upper respiratory infections (URI) are available for ambulatory patients with cancer.

Adult cancer patients with URI who presented to the Urgent Care Center or Symptom Care Clinic (SCC) and had a respiratory pathogen panel (RPP) between September 1, 2019 and March 11, 2020, were evaluated. Patients were dichotomized by receipt of antibiotic prescription (yes vs no). Demographics, cancer treatment, URI characteristics, and URI management were compared by Student’s t test or Mann–Whitney U test and χ2 or Fisher’s exact test as appropriate. Logistic regression was performed to evaluate predictors of antibiotic prescription.

Of 552 patients, 384 (69.6%) received cancer treatment within 30 days of the URI, and 377 (68.3%) had a positive RPP result. Antibiotics were prescribed in 156 (28.3%) patients, and 26/156 (16.7%) were appropriate. Multivariate logistic regression showed that predictors of antibiotic prescribing included SCC visit location (odds ratio (OR) 2.09, 95% confidence interval (CI) 1.30–3.38), symptom duration >7 days (OR 2.29, 95% CI 1.26 – 4.17), earache (OR 9.30, 95% CI 3.47 – 24.93), sinus symptoms (OR 2.64, 95% CI 1.53 – 4.56), negative RPP result (OR 1.88, 95% CI 1.18 – 2.98), and negative RPP result for influenza (OR 3.31, 95% CI 1.53 – 7.16).

Almost one-third of outpatients at a single cancer center were prescribed antibiotics for URI with only 16.7% being appropriate. Getting real-time RPP results can be helpful to optimize antibiotic prescribing. Understanding risk factors for antibiotic prescribing in ambulatory cancer patients with URI may better direct antimicrobial stewardship efforts.

We recently added C. diff toxin assay to polymerase chain reaction (PCR) as a two-tier algorithm to investigate whether this approach improves patient outcomes and antibiotic stewardship.

Retrospective chart review.

305-bed acute care urban teaching hospital.

All inpatients admitted who tested positive for C. diff by PCR. Testing was performed by provider order on clinical suspicion of infection. Exclusion criteria were patients with chronic diarrhea, history of IBD, and recent gastric bypass surgery.

On April 1, 2023, the two-tier testing algorithm was implemented for patients who tested positive by PCR. The EMR was reviewed through May 1, 2024, to determine whether toxin-positive patients differed from toxin-negative patients with respect to their demographics, clinical characteristics, outcomes, and initiation of antibiotic treatment.

Of 147 consecutive C. diff PCR-positive patients, 32% tested toxin-positive (n = 57) and 51% toxin-negative (n = 90). Demographics were similar across groups. Toxin-positive patients showed more symptoms of colitis, more bloating, a higher average white blood cell count, and had a higher fatality rate. Antibiotics were more commonly prescribed to toxin-positive patients (98%) than toxin-negative patients (56%) (p < 0.01). Of the 90 patients who were toxin-negative, 44% of those were not treated with antibiotics.

Our study supports previous findings that a two-tier testing strategy effectively identifies active C. diff infection rather than colonization, effectively improving antibiotic stewardship efforts. Some toxin-negative patients also had colitis symptoms and responded to antibiotics, indicating that clinical judgment is still needed in cases with discrepant results.