To identify global research priorities for improving hand hygiene in healthcare settings and develop a 2023–2030 research agenda to guide funding, coordinate research, promote investment, and inform policy for enhanced healthcare quality and safety.

Expert consensus study using a modified Delphi process.

A 105-member panel of international hand hygiene experts including the World Health Organization (WHO) Technical Advisory Group of Experts on Hand Hygiene in Healthcare representing all WHO regions and World Bank income levels.

The research priorities were identified through a multiphase approach including a meta-review to establish knowledge gaps and inform initial priorities, followed by expert consultations using a modified Delphi process. 192 preliminary priorities were included in a two-round Delphi survey. Experts rated each priority in the first round, and then reviewed and adjusted responses based on the panel’s aggregated, anonymous responses in the second round. Ratings were collected on a five-point Likert scale. Consensus was defined as a combined “strongly agree” and “agree” frequency of at least 70%.

Consensus was achieved for 178 of 192 priorities (92.7%), categorized into six domains: system change; training and education; evaluation and feedback; reminders and communications; institutional safety climate; and hand hygiene improvement impact on healthcare-associated infections and antimicrobial resistance. Of these, 121 priorities reached >80% consensus. The Delphi process, maintained a 92% response rate over two rounds.

A structured consensus process yielded a research agenda to address gaps in hand hygiene improvement, supporting enhanced healthcare quality and safety globally.

Concerns about penicillin-cephalosporin cross-reactivity have historically led to conservative prescribing and avoidance of cephalosporins in patients with penicillin allergy labels, potentially causing suboptimal outcomes. Recent evidence suggests a lower risk of cross-reactivity, prompting a reassessment of alert systems.

To assess the impact of limited penicillin cross-reactivity alerts on outpatient cephalosporin use and the incidence of adverse reactions in a healthcare setting.

This retrospective cohort study compared cephalosporin prescribing and adverse reactions in patients labeled as penicillin-allergic before and after limiting penicillin cross-reactivity alerts in the electronic medical record at a large academic medical center.

Among 17,174 patients (8,131 pre- and 9,043 post-implementation), there was a statistically significant increase in outpatient cephalosporin prescribing by 8% (P < .001). The use of alternative antibiotic classes decreased. There was no statistically significant increase in adverse events pre- and post-implementation (0.036%–0.058%, P = .547), and no severe events were attributable to cross-reactivity. The alert modification reduced alerts by 92% (P < .001).

The reduction of penicillin-cephalosporin cross-reactivity alerts was associated with increased cephalosporin use, without a significant increase in adverse reactions. This demonstrates that the practice is safe and decreases alert burden.

Evaluate Department of Defense (DoD) antimicrobial stewardship programs (ASPs) by assessing the relationship between key clinical outcome metrics (antibiotic use, incidence of resistant pathogens, and incidence of Clostridioides difficile infections) and CDC Core Element (CE) adherence.

Retrospective, cross-sectional study of DoD hospitals in 2018 and 2021

National Healthcare Safety Network Standardized Antimicrobial Administration Ratios (SAARs) were used to measure antibiotic use and microbiology results to evaluate four types of pathogen incidence. A novel CE scoring approach used scores to quantitatively assess relationships with CE adherence and outcome metrics using correlation and regression models. Assessments were repeated with 2021 data for Priority CE adherence and to conduct adjusted regressions for CEs and Priority CEs controlling for categorical bed size.

Compared to 2022 national data, DoD hospitals in 2021 had a similar proportion of facilities with a SAAR statistically significantly > 1.0. Leadership, Action, and Tracking CEs followed a more normal score distribution, while Reporting and Education were somewhat left-skewed. Unadjusted models often showed a positive relationship with higher CE scores associated with worse outcomes for the SAAR and pathogen incidence. Adjusted models indicated that procedural CEs, particularly Priority Reporting, were associated with better ASP-related outcomes.

CEs should be more quantitatively assessed. Results provide initial evidence to prioritize procedural CE implementation within the DoD; however, additional investigation for structural CEs is needed. Patient outcome data should be collected as an important indicator of ASP performance.

To better understand clinicians’ rationale for ordering testing for C. difficile infection (CDI) for patients receiving laxatives and the impact of the implementation of a clinical decision support (CDS) intervention.

A mixed-methods, case series was performed from March 2, 2017 to December 31, 2018.

Yale New Haven Hospital, a 1,541 bed tertiary academic medical center.

Hospitalized patients ≥ 18 years old, and clinicians who were alerted by the CDS.

CDS was triggered in real-time when a clinician sought to order testing for CDI for a patient who received one or more doses of laxatives within the preceding 24 hours.

A total of 3,376 CDS alerts were triggered during the 21-month study period from 2,567 unique clinician interactions. Clinicians bypassed the CDS alert 74.5% of the time, more frequent among residents (48.3% bypass vs. 39.9% accept) and advanced practice providers (APPs) (34.9% bypass vs. 30.6% accept) than attendings (11.3% bypass vs. 22.5% accept). Ordering clinicians noted increased stool frequency/output (48%), current antibiotic exposure (34%), and instructions by an attending physician to test (28%) were among the most common reasons for overriding the alert and proceeding with testing for CDI.

Testing for CDI despite patient laxative use was associated with an increased clinician concern for CDI, patient risk for CDI, and attending physician instruction for testing. Attendings frequently accepted CDS guidance while residents and APPs often reinstated CDI test orders, suggesting a need for greater empowerment and discretion when ordering tests.

Central line-associated bloodstream infections (CLABSIs) result in morbidity and mortality among hospitalized patients. Hospital interventions to reduce the incidence of CLABSI are often broadly applied to all patients with central venous access. Identifying central lines at high risk for CLABSI at time of insertion will allow for a more focused delivery of preventative interventions.

This was an observational cohort study conducted at three hospitals including all patients who received central venous access. CLABSIs were identified using an institutional CLABSI database maintained by the hospital epidemiology team. Logistic regression (LASSO) and machine learning (random forest, XGboost) techniques were applied for the prediction of CLABSI occurrence, adjusting for selected patent and insertion-level characteristics.

A total of 40,008 central venous catheters were included, of which 409 (1.02%) were associated with CLABSI. The random forest and the XGBoost models had the highest discrimination (Area Under the Received Operating Curve [AUC] 0.79) followed by LASSO (0.73). High illness severity, receipt of total parenteral nutrition, receipt of hemodialysis, pre-insertion hospital length-of-stay, and low albumin levels were all predictive of CLABSI occurrence. Precision for all models was poor owing to a high false-positive rate.

CLABSI can be predicted based upon patient and insertion level factors in the electronic health record. In this study, random forest and gradient-boosted models had the highest AUC. Prediction cut-offs for the identification of CLABSI can be adjusted based upon the acceptable rate of false-positives for a given CLABSI preventative intervention.

To retrospectively observe procalcitonin (PCT) and antibiotic ordering practices in patients hospitalized with community-acquired pneumonia (CAP).

Retrospective, exact matched, multicenter cohort study from October 1, 2018 – March 31, 2023.

All hospitals across the Mayo Clinic Enterprise.

Adult patients with CAP, identified using pneumonia diagnosis codes and receipt of systemic antibiotics with an indication of “respiratory tract infection” within 48 hours of hospitalization.

PCT testing within the first 7 days of hospitalization was compared to non-PCT care (nPCT). The primary outcomes were treatment duration, antibiotic days of therapy (DOT), and length of stay (LOS).

15364 patients met inclusion criteria. PCT testing occurred in 42.4% (6515/15364) of encounters, totaling 8214 PCT results. 12880 unique patient encounters were matched 1:1, 6440 in each group. Treatment duration was longer in the PCT group compared to the nPCT group (5.1 vs 4.6 days, respectively, P < 0.001). Patients in the PCT group also received more DOT (8.6 vs 7.6 DOT, P < 0.001) and had a longer LOS (6.8 vs 5.9 days, P < 0.001), respectively. There was no difference in 30-day all-cause mortality or C. difficile infection between groups. In a sensitivity analysis of nPCT patients compared to those with a peak value <0.25 ng/mL (i.e. normal result) there was no difference in treatment duration (4.6 days nPCT vs 4.7 days normal PCT, P = 0.104) or LOS (5.9 days nPCT vs 6.0 days normal PCT, P = 0.134).

PCT testing in patients hospitalized with CAP was not associated with reduced antimicrobial utilization, LOS, or 30-day all-cause mortality.

Intensive care units (ICUs) and high-dependency units (HDUs) care for critically ill patients, many of whom have multi-drug-resistant (MDR) bacteria. We investigated the prevalence and distribution of MDR bacteria on the surfaces of patient medical files in three ICUs and two HDUs in Kampala.

We conducted a cross-sectional study that used simple random sampling to select patient medical files through unique codes recorded in a health information electronic system. MDR was defined as laboratory confirmation of the WHO priority pathogens following the 33rd edition of the Clinical Laboratory Standards Institute on Antimicrobial Susceptibility testing guidelines for antibiotic susceptibility interpretation. Quantitative data was descriptively analyzed, while qualitative was thematically analyzed.

Six of 33 files (18.2%) had MDR bacteria on their surfaces. Contamination was significantly associated with the type of medical diagnosis (p=0.014) and the file storage location (p=0.010). The MDR pathogens identified were Fastidious Acinetobacter (5/33; 15.2%) and methicillin-resistant Staphylococcus aureus (1/33; 3%).

Nearly one in five patient medical files in ICUs and HDUs were contaminated with MDR bacteria. Most contaminated files belonged to patients treated with aminoglycoside or glycopeptide-based regimens.

Hospital-onset bacteremia and fungemia (HOB) has been suggested as a suitable and automatable surveillance target to include in surveillance programs, however differences in definitions across studies limit interpretation and large-scale implementation. We aimed to apply an automated surveillance system for HOB in multiple hospitals using a consensus definition, and describe HOB rates.

Retrospective cohort study in four Dutch hospitals: 1 tertiary hospital and 3 secondary hospitals.

All patients admitted for at least one overnight stay between 2017 and 2021 were included, except patients in psychiatry wards.

Data from the electronic health records and laboratory information system were used to identify HOBs based on the PRAISE consensus definition. HOB rates were calculated at ward and micro-organism-level.

Hospital-wide HOB rates varied from 1.0 to 1.9, and ICU rates varied from of 8.2 to 12.5 episodes per 1000 patient days. The median time between admission and HOB was 8–13 days. HOBs were predominantly caused by Enterobacterales, Enterococci, S. aureus and coagulase-negative staphylococci. Longitudinal HOB surveillance detected differences over time at ward and micro-organism level; for example increased HOB rates were observed during the COVID-19 pandemic. Sensitivity analyses demonstrated the impact of assumptions regarding the collection of confirmatory blood cultures for common commensals.

Applying a fully automated definition for HOB surveillance was feasible in multiple centers with different data infrastructures, and enabled detection of differences over time at ward and micro-organism-level. HOB surveillance may lead to prevention initiatives in the future.

Asymptomatic patients colonized with toxigenic Clostridioides difficile are at risk of progressing to C. difficile infection (CDI), but risk factors associated with progression are poorly understood. The objectives of this study were to estimate the incidence and identify risk factors to progression of hospital-onset CDI (HO-CDI) among colonized patients.

This was a nested case-control study at an academic medical center including adult patients colonized with toxigenic C. difficile, detected via polymerase chain reaction (PCR) on a rectal swab collected on admission from 2017 to 2020. Patients with prior CDI or symptoms on admission, neutropenia, prior rectal surgery, or hospitalization less than 24 hours were excluded. Colonized patients that developed HO-CDI were matched 1:3 to colonized patients who did not based on PCR test date. Bivariate and multivariable-adjusted Cox regression analyses were used to identify risk factors.

Of 2,150 colonized patients, 109 developed HO-CDI, with an incidence of 5.1%. After exclusions, 321 patients (69 with HO-CDI) were included, with an estimated incidence of 4.2%. Risk factors included cirrhosis (aHR 1.94), ICU admission (aHR 1.76), malignancy (aHR 1.88), and hospitalization within six months (aHR 1.6). Prior antibiotic exposure in the past three months (aHR 2.14) and receipt of at-risk antibiotics were also identified as potential risk factors (aHR 2.17).

Progression to HO-CDI among colonized patients was not uncommon. This study highlights key risk factors associated with progression, underscoring the importance of enhanced monitoring and prevention efforts tailored to high-risk populations to mitigate HO-CDI.

To evaluate the hospital-reported cost of care, clinical burden, and incidence of hospital-onset bacteremia and fungemia (HOB) for hospital admissions with surgical site infections (SSI).

A cross-sectional study of 38 acute-care hospital admissions with a procedure under the National Healthcare Safety Network (NHSN) surveillance for SSI was conducted. SSI admissions were identified through NHSN reporting by the hospital. Clinical outcomes were estimated for SSI compared to no SSI controls using propensity matching and multivariable adjusted models that controlled for patient and hospital demographics; these endpoints were also compared for SSI admissions with and without HOB co-occurrence.

The rate of hospital-reported SSI was 0.15 per 100 admissions with a procedure under surveillance for SSI. Admissions with SSI compared to no SSI had significantly higher incremental hospital-reported cost of $30,689 and length of stay (LOS) was 11.6 days higher. The incidence of HOB was 6-fold higher in admissions with SSI compared to no SSI. For SSI admissions with HOB vs. no HOB, HOB added $28,049 to cost of care and 6.5 days to the LOS.

Hospital-reported SSIs were associated with higher clinical and economic burden. Patients with SSI and HOB had even more deleterious outcomes. These data may inform programs to augment infection prevention bundles targeting SSIs and downstream complications or comorbidities like HOB.