Older adults (≥65) often receive antibiotics in emergency departments (ED), where guideline concordance is low with both overuse and underuse; whether community disadvantage drives these patterns is unknown.

We analyzed electronic health records from 1,318,281 ED encounters among 790,562 adults ≥65 (2015–2024). Outcomes were guideline concordance and components (overuse, underuse). To address omitted variables and reverse causality, we used two-stage instrumental-variable models with Social Vulnerability Index (SVI) and Social Deprivation Index (SDI) as exposures, instrumented by maximum state Earned Income Tax Credit, adjusting for patient, facility, state, and time covariates.

16.8% of encounters were non-concordant (overuse 9.5%; underuse 7.2%). Concordance improved to 83.8% in 2024. In IV models, each 10-point increase in SVI reduced concordance by 6.37 percentage points (pp) (SE 0.69) and each 10-point increase in SDI by 1.84 pp (SE .20; P < .0005). Declines reflected higher underuse (+0.43 pp per 10-point SVI; +0.12 pp per 10-point SDI) with less overuse (−0.10 and −0.30 pp). Concordance was higher for Black (+12.90 pp vs White) and Medicaid-insured patients (+5.40 pp vs commercial). Overuse was higher in rural (+7.90 pp vs metropolitan) and academic EDs (+5.00 pp vs non-academic), whereas underuse was more common in metropolitan (+42.50 pp) and non-academic EDs (+32.70 pp). Spatial analyses found high deprivation/low concordance in the South and low deprivation/high concordance in the Midwest.

Community disadvantage may causally predict lower guideline-concordant antibiotic prescribing for older adults, primarily via underuse. Stewardship should address underuse and overuse and prioritize disadvantaged regions where gaps are greatest.

To understand current practices for screening, implementing and clearing contact precautions (CP) for multidrug-resistant organisms (MDRO).

A survey of US-based SHEA Research Network (SRN) members and Community Healthcare Epidemiologists and Stewards (CHES).

The SRN is a consortium of healthcare facilities collaborating on multicenter research projects. CHES is an SRN-affiliated group of community hospital epidemiologists.

A Research Electronic Data Capture (REDCap) survey was administered between January 7, 2025 and February 25, 2025. Frequencies and proportions were calculated in REDCap and Microsoft Excel. Fisher’s exact and χ2 tests were calculated in R.

Of 134 facilities, 60 (45%) responded; 4 answered only demographic questions and were excluded from analysis. Most facilities (70%) performed active surveillance for ≥1 MDRO, but only 16% employed preemptive CP. All respondents reported using CP for ≥1 MDRO. CP were employed more often for infection than colonization. Clearance protocols to discontinue CP were common for MRSA (97%), C. difficile (95%), and vancomycin-resistant enterococci (82%), but uncommon for Gram-negatives. Training and adherence of frontline staff (70%), unavailability of private rooms (41%), and lack of evidence-based strategies to eradicate reservoirs (34%) were the top 3 identified barriers to MDRO infection control and prevention.

Infection control practices varied by infection, colonization, specific MDRO, and time to clearance. Variation may indicate need for more data on transmission risk by disease state, organism, and time. Evidence-based strategies are needed to guide MDRO prioritization and CP duration and clearance policies. Guidance should acknowledge limitations in adherence, availability of private rooms, and persistent environmental reservoirs as major barriers to MDRO containment identified in this survey.

Describe the first healthcare-associated outbreak of Candida auris in Maricopa County, Arizona. Also, outline the Maricopa County Department of Public Health (MCDPH) response activities to halt transmission and identify affected healthcare facilities (HCFs) and contacts colonized with C. auris.

At HCFs with confirmed C. auris cases (i.e., exposed HCFs), MCDPH provided virtual infection control assessment and response activities, including contact investigations among hospitalized patients and point prevalence surveys (PPSs) to identify ongoing transmission. Confirmed C. auris cases included C. auris detected by cultures or polymerase chain reaction (PCR) in a hospitalized patient. Clinical cases had C. auris from cultures obtained during routine care in a hospitalized patient. Colonized cases included C. auris detected by PCR obtained from hospitalized patients for screening purposes.

On April 21, 2022, the first clinical case was identified, resulting in an outbreak with C. auris screening at 28 exposed HCFs. In total, 39 clinical C. auris cases were reported. Among 1,994 contacts identified, 899 (45.0%) were screened, 8 (0.4%) declined screening, and 1,087 (54.5%) were ineligible for screening (i.e., no longer hospitalized in Maricopa County). Among screened patients, 158 (17.6%) were colonized with C. auris; 15 (9.5%) colonized contacts later acquired clinical infections. This outbreak concluded on February 23, 2023, after 2 consecutive PPSs yielded no C. auris detection at exposed HCFs.

The first C. auris outbreak in Maricopa County highlights the coordinated efforts between HCFs, laboratories, and public health to identify exposed HCFs, screen contacts, and halt C. auris transmission.

Multidrug-resistant organisms (MDROs) such as carbapenem-resistant Enterobacterales (CRE) are a significant public health threat. Patients colonized with MDROs are at higher risk of severe outcomes and can serve as a source of spread to others. The public health impact of a hypothetical agent that reduces MDRO load (i.e., pathogen reduction), including in the gastrointestinal tract, has not been described.

Compartmental models of CRE transmission in healthcare facilities were used to estimate the impact of a hypothetical pathogen reduction agent on CRE bloodstream infections (BSIs) and deaths.

The agent was assumed to reduce the time to pathogen clearance with effectiveness varying from 25–100% across simulations. Interventions were modeled in acute care hospitals (ACHs), critical access hospitals, long-term acute care hospitals (LTACHs), skilled nursing facilities, and ventilator-capable skilled nursing facilities (vSNFs). Direct effects (among patients who received the agent) and indirect effects (among patients who did not receive the agent) were estimated at the national healthcare network level.

At baseline without intervention, an estimated 2,086 CRE BSIs and 622 associated deaths occurred annually nationwide. Use of a pathogen reduction agent in LTACHs and vSNFs averted 69–75% of CRE BSIs nationally, with greater reductions when expanded to all facility types. Approximately 90% of averted CRE BSIs would have occurred in patients who were not administered the agent.

An effective pathogen reduction agent might substantially reduce MDRO infections and deaths among patients in U.S. healthcare facilities. New and expanded efforts are needed to accelerate the development of such products.

To report on the investigation of a pseudo-outbreak of Mycobacterium mucogenicum and examine its clinical and operational impact.

Outbreak investigation, retrospective cohort study.

Academic medical center in Los Angeles, California.

Patients whose bronchoalveolar lavage (BAL) cultures grew M. mucogenicum from 2020–2024.

We performed an institutional outbreak investigation of M. mucogenicum, reviewed electronic medical records of a subset of affected patients (2023–2024), and assessed the operational impact.

The incidence of M. mucogenicum in BAL cultures at Hospital A increased from 6.1% (29/473) in 2020 to 18.6% (29/156) in the first quarter of 2024. Epidemiologic investigation revealed non-sterile ice baths used to cool uncapped sterile syringes during bronchoscopy procedures as the contamination source. Next generation sequencing linked clinical isolates to M. mucogenicum recovered from a perioperative ice machine. Nearly all (157/160) clinical isolates grew from nocardia media rather than acid-fast bacilli media. Among 154 patients, including 51 (33.1%) who were highly immunocompromised, no true infections were identified. Thirty-nine (25.3%) patients were referred to infectious diseases for consultation, seven (4.5%) underwent additional workup, and only one received targeted treatment. The pseudo-outbreak incurred 458 hours of microbiology technologist and infection preventionist time and cost the laboratory $88,426.

A four-year pseudo-outbreak of M. mucogenicum traced to contaminated ice baths used during bronchoscopy resulted in unnecessary infectious disease referrals and substantial operational and financial burden to the institution. Avoidance of non-sterile ice use in procedures prevents costly and burdensome pseudo-outbreaks of environmental mycobacteria in healthcare settings.

Understand current Candidozyma auris prevention practices in the United States and identify opportunities to improve containment.

Electronic survey.

Acute care hospitals.

Society for Healthcare Epidemiology (SHEA) Research Network (SRN) facilities located in the United States.

REDCap survey distributed via email exploring knowledge and perceptions related to C. auris screening methods, prevention practices, barriers to prevention, and tools needed to improve containment.

Responses were received from 51/96 (53%) U.S.-based SRN facilities, with 80% identifying as teaching hospitals. Two-thirds of facilities (34/51) reported first-hand experience with C. auris, with 15/34 also experiencing at least one C. auris outbreak. Routine C. auris screening occurred in 47% (24/51) of facilities. C. auris prevention practices commonly included patient isolation, signage to notify staff of isolation status, and placement in a single patient room. When asked to identify barriers to control of C. auris at their facility, participants ranked lack of communication between healthcare facilities, lack of infection control at outside healthcare facilities, and lack of training as the top three barriers. C. auris prevention resources or tools perceived to be most helpful in their facility included effective decolonization regimens, standardized protocols for C. auris screening, and improved communication between healthcare facilities.

SRN facilities commonly used isolation practices to prevent the spread of C. auris. Development of additional tools to improve prevention practices should target effective decolonization strategies and standardized screening protocols to support C. auris containment.

Professional guidelines recommend an early switch from intravenous (IV)-to-oral antibiotics for community-acquired pneumonia (CAP) to facilitate early discharge and prevent hospital-related complications. However, it is unknown how often these IV-to-oral switches occur in clinical practice.

We performed a retrospective cohort study across 124 acute-care Veterans Administration hospitals to measure the frequency of early switches.

Patient-admissions during 2018–2023 who had CAP and were started on IV antibiotics upon admission.

We measured the percentage of hospitalized patients with CAP who had an early switch from IV-to-oral antibiotics, i.e., within 72 hours of admission. In addition, we calculated an observed-to-expected ratio for early switches at each hospital and compared a composite outcome (mortality and/or hospital readmission within 30 days of discharge) at hospitals with switch rates that were higher and lower than expected.

Of 31,183 patient-admissions for CAP, 17,282 (55.4%) were switched to oral antibiotics by day three of therapy. Overall, 5,629 (18.1%) died and/or were re-admitted within 30 days. The O:E ratio for early antibiotic switches ranged from 0.78 among hospitals in the lowest quartile to 1.23 in the highest quartile. There was no difference in the composite outcome across quartiles.

Early switches from IV-to-oral antibiotics for CAP occurred in half of eligible cases. The frequency of these switches varied widely across facilities. Outcomes among patients at hospitals with high switch rates were comparable to outcomes at hospitals with low rates, thereby supporting the safety of early switches. More concerted efforts to promote these switches are needed.

This study aims to evaluate the effectiveness of an adapted methicillin-resistant Staphylococcus aureus (MRSA) decolonization program in an infirmary unit in Hong Kong that was inspired by successful interventions implemented in Orange County, California.

Nasal, skin, and rectal swabs were collected to assess MRSA colonization. Decolonization involved applying 10% povidone-iodine ointment to the anterior nares twice daily for five days every other week, along with twice weekly chlorhexidine gluconate (CHG) bathing for six months. Compliance with the application of povidone-iodine and CHG bathing techniques was monitored by measuring their respective levels in the anterior nares and on the skin. Air and environmental samples were collected and analyzed over time using linear regression.

Among 60 patients in the infirmary unit (78% baseline MRSA carriers), overall MRSA colonization declined during the program, driven by significant reductions in skin colonization (65% to 29%, P < .001). Environmental contamination on high-touch patient-care equipment (bathing trolleys and slings) also significantly decreased over time (P < .001). These reductions coincided with the high-quality implementation of decolonization, evidenced by stable iodophor detection in nares during application weeks and sustained chlorhexidine levels on the skin, detectable 24 hours after bathing. In contrast, MRSA detection in air samples showed no significant change (P = .096), possibly due to dispersal by persistent carriers during care activities even as skin and environmental contamination declined.

The adapted MRSA decolonization program was effective, significantly reducing overall MRSA colonization, especially at skin sites, while achieving high compliance with the protocol.

Surveillance activities are emerging as exemplar use cases for large language models (LLMs) in health care. The aim of this study was to evaluate the potential for LLMs to support the expansion of surveillance activities to include cardiovascular implantable electronic device (CIED) procedures.

A validated machine learning-based infection flagging tool was applied to a cohort of VA CIED procedures from 7/1/2021 to 9/30/2023; cases with ≥10% probability of CIED infection underwent manual review. Then, a weighted random sample of 50 infected and 50 uninfected cases was reviewed with generative artificial intelligence (GenAI) assistance. GenAI prompts were iteratively refined to extract and classify all components of infection-related variables from clinical notes. Data extracted by GenAI were compared with manual chart reviews to assess infection status and extraction consistency.

Among 12,927 CIED procedures, 334 (2.58%) had ≥10% probability of CIED infection. Among 100 sampled cases, 50 of 50 uninfected cases were correctly categorized. Among 50 infection cases, GenAI identified all CIED infections, but the timing of events and the attribution to a preceding procedure were incorrect in 7 of 50 cases. The overall specificity of the GenAI-assisted process was 100% and the sensitivity for accurately classifying timing and attribution of CIED infection events was 82%. Errors in timing improved with iterative prompt updates. Manual chart reviews averaged 25 minutes per chart; the GenAI-assisted process averaged 5–7 minutes per chart.

LLMs can help streamline the review process for healthcare-associated infection surveillance, but manual adjudication of output is needed to ensure the correct timeline of events and attribution.

To evaluate the implementation and effectiveness of a novel home infusion central line-associated bloodstream infection (CLABSI) and home infusion-onset bloodstream infection (HiOB) dashboard and prevention toolkit.

Mixed methods study.

Five home infusion agencies participating in the first CLABSI prevention collaborative.

Agencies uploaded CLABSI and HiOB data to a comparative dashboard. The dashboard started in December 2022 and accepted retrospective data from June 2021. A CLABSI prevention toolkit was made available in June 2024. Using an interrupted time series, we present CLABSI and HiOB rates before and after dashboard and toolkit implementation. We surveyed and interviewed participants about the tools and toolkit, using directed content analysis to analyze the interviews.

After dashboard implementation, there was a decrease in CLABSI (−0.23/10,000 home-CVC days, 95% CI −0.28 to −0.18) and HiOB (−0.25/10,000 home-CVC days, 95% CI: −0.31 to −0.18) over time. With toolkit implementation, there was a further decrease in CLABSI (−0.17/10,000 home-CVC days, 95% CI: −0.30 to −0.044) and HiOB (−0.23/10,000 home-CVC days, 95% CI: −0.37 to −0.089) over time. Themes were associated with use of the tools (accessible, adaptable, patient-centered tools; user-friendly education to enhance understanding; barriers identified; tool mismatches; and strategies for tool delivery) and toolkit implementation (structural barriers, user-centered design, collaborative engagement and communication, toolkit used to enhance workforce competency, and concerns related to consistency).

Implementation of a dashboard and a CLABSI prevention toolkit were each associated with both CLABSI and HiOB reduction in a collaborative of home infusion agencies.