Despite the availability of straightforward and economic interventions to prevent HAIs, these unintentional adverse events still pose a significant challenge to public health globally. We aimed to evaluate the outcomes of a nationwide project designed to mitigate HAI incidence in intensive care units (ICUs) using the Model of Improvement framework.

A Quality Improvement (QI) study assessing the outcomes of a two-year initiative in Brazilian ICUs from September 2021. A customized Collaborative methodology was applied to mentor and enhance the capabilities of healthcare workers, equipping them with evidence-based, structured, systematic, and auditable QI strategies (prevention bundles) to improve patient care outcomes. A one-year preintervention baseline incidence was established for the three critical HAIs: central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTI), to compare with the intervention period.

The initiative encompassed 188 ICUs (169 adults, 11 pediatric, and eight neonatal), recording substantial reductions in HAI incidence density: by 43% for CLABSI (from 5.5 to 3.2 per 1,000 catheter-day), by 51% for VAP (from 13.6 to 6.7 per 1,000 ventilator-day), and by 55% for CAUTI (from 3.2 to 1.4 per 1,000 catheter-day), irrespective of age. Implementing this QI strategy prevented an estimated 7,342 infections.

Our initiative has been demonstrated to be a feasible and valuable strategy for preventing HAIs in critical care settings. The success of this approach emphasizes the potential for its broader application and reinforces the need for systematic, evidence-based interventions in healthcare settings.

To identify modifiable surgical practices associated with reduced sternal wound infection rates following isolated coronary artery bypass grafting (CABG) using positive deviancy methodology.

Retrospective cohort study with prospectively collected data (January 2021–June 2025).

Single tertiary referral cardiac surgery center.

3,087 consecutive patients undergoing isolated CABG.

Primary outcome was total sternal wound infection (deep and superficial combined) within 30 days. Risk-adjusted surgeon performance was evaluated using mixed-effects logistic regression with observed-to-expected (O/E) ratios. Positive deviants were defined as surgeons with O/E ratios <1.0 with 95% confidence intervals excluding unity. Surgical techniques were systematically reviewed through anonymized surveys, and volume-weighted analysis compared techniques of better and worse performers.

Total sternal wound infection occurred in 175 patients (5.7%). Nine surgeons were stratified: better performers (O/E <1.0, n = 5), worse performers (O/E ≥1.2, n = 3), and average performers (O/E 1.0–1.19, n = 1). One surgeon achieved statistically significant superior performance (O/E = 0.590, 95% CI: 0.39–0.91), representing 41% fewer infections than expected across 543 cases. Four protective techniques were identified: wound irrigation at closure (100% vs 0%), double skin preparation with chlorhexidine and povidone (100% vs 0%), superior Ioban adherence quality (5/5 vs 3.7/5 vs 3.2/5, P < .001), and minimal cautery usage (1.0/5 vs 3.2/5 vs 3.5/5, P < .001).

Positive deviancy methodology successfully identified four modifiable surgical practices associated with reduced total sternal wound infections. These techniques represent immediately implementable interventions for infection prevention in cardiac surgery. Further study is needed to validate these findings across multiple institutions and evaluate implementation outcomes.

The implementation of the World Health Organization’s multimodal strategy is crucial for strengthening infection prevention and control (IPC) programs. This study aimed to evaluate and compare the perceptions of infection prevention and control professionals (IPCPs) and healthcare workers (HCWs) regarding the effectiveness of the multimodal strategy.

In this study, an online survey was designed that included five MM components: system change, education and training, monitoring and feedback, reminders and communication, and cultural change. The survey was completed by IPCPs and HCWs within the institutions.

A total of 102 IPCPs and 166 HCWs from 96 institutions participated in the survey. The mean career duration was 19.8 ± 9.5 years. An Infection Control Committee (ICC) was present in 98% of participants’ institutions, and 88% held meetings every three months. Only 10 (10.4%) institutions met the ratio of 1IPC nurse per 150 beds. Effective communication techniques training was provided annually to 55.9% of IPCPs and 59.6% of HCWs.

Eighty-one (79.4%) IPCPs reported using effective communication when explaining the five indications of hand hygiene, but only 77 (46.4%) HCWs agreed (P < .001). Ninety-one (89.2%) IPCPs confirmed that effective communication techniques were used in bundle training. But, only 25 (15.0%) HCWs agreed, while 112 (67.5%) HCWs reported being undecided (P < .001). Sixty-one (64.7%) IPCPs and 130 (78.3%) HCWs believed that their institutions effectively motivated HCWs towards IPC measures compliance. However, 44 (43.1%) IPCPs and 29 (17.5%) HCWs were undecided (P = .002).

The survey reveals significant inconsistencies among IPCPs and HCWs regarding communication effectiveness, and perceptions of compliance with infection-control measures. These findings highlight the need for more inclusive and transparent communication strategies, regular interdisciplinary training, and stronger organizational support to improve IPC practices.

Chlorhexidine gluconate (CHG) skin treatments are an effective strategy to reduce patients’ risk of central line-associated bloodstream infection (CLABSI); however, compliance with this practice is suboptimal. One barrier is patient refusal of CHG skin treatments. To mitigate this barrier, the purpose of this study was to evaluate the feasibility and outcomes of implementing a patient-facing CHG skin treatment educational video on an inpatient adult bone marrow transplant (BMT) unit.

A quasi-experimental pre–post research study design was used.

The study took place at a large academic hospital in the Southeastern U.S.

Patients admitted to a 16-bed BMT unit were included.

A patient-facing CHG skin treatment educational video was developed with input from a multidisciplinary team, patients, and their family members. Patients accessed the video through a QR code or website link provided on a laminated document.

The video was viewed 173 times, with an average of 84% of the video watched. Of the 117 patients who completed a feedback survey, most felt the video was helpful and increased their likelihood of participating in CHG skin treatments. No improvements were shown in documented CHG compliance or patient refusals. A 27.2% reduction in the CLABSI rate was found, with a decreased rate of 2.54 to 1.85 post-intervention, although this reduction was not statistically significant, P = .58.

While patients found the video beneficial, future research that includes more diverse patient populations is needed to better understand the long-term impact of a CHG skin treatment educational video.

Nursing home residents have been disproportionately impacted by respiratory virus-related morbidity and mortality due to inherent vulnerability and communal living environments. This study aims to identify nursing homes with higher infection rates during a period of intense SARS-CoV-2 transmission and explore facility-level characteristics potentially associated with infection surges.

A longitudinal k-means clustering approach followed by exploratory regression analyses.

U.S. Nursing homes reporting to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN).

A longitudinal k-means method (kmlShape) classified the facilities based on their weekly SARS-CoV-2 incidence rate epidemic curve, identifying two categories (low vs high infection peak) based on the magnitude of infection peaks. A logistic regression model with bootstrapping was developed to assess facility characteristics associated with higher SARS-CoV-2 infection surges.

Among 11,990 nursing homes analyzed, 9,058 were classified as having a low infection peak, while 2,932 had a high infection peak. Nursing homes that are for-profit (OR = 1.570, 95% bootstrap confidence interval [BCI] 1.441–1.807), with high staff turnover (OR = 1.292, 95% BCI 1.154–1.451), or located in areas with higher social vulnerability (OR = 1.457, 95% BCI 1.239–1.880) were more likely to experience high infection peaks. Nursing homes with higher residents’ vaccination coverage (OR = .321, 95% BCI .248–.380) and located in urban areas were less likely to experience high infection peaks.

The facility-level characteristics associated with lower SARS-CoV-2 infection peaks may indicate resiliency and help evaluate the capacity of nursing homes to endure stressors such as respiratory viruses and other communicable illnesses.

Heating, ventilation, and air conditioning (HVAC) systems can modulate the risk of respiratory virus transmission. In congregate living settings (CLS), variability in the quality of this infrastructure presents an improvement opportunity.

We performed a cross-sectional study of the air handling units (AHU) of HVAC systems across a network of CLS to identify the most common problems and specific opportunities to improve ventilation. A third-party expert performed systematic HVAC assessments, which were analyzed based on presence and function of key AHU components to determine their association with air changes per hour (ACH) using a multivariable linear regression model.

Across 15 participating CLS, the median ACH was 3.3 (IQR = 10.4) in common areas, 3.5 (IQR = 12.6) in resident rooms, and 6.6 (IQR = 9.7) in resident bathrooms. Closed outside air dampers and fans turned off was associated with decreased ACH in resident rooms (−9.5 ACH, 95% CI, −0.2 to −18.9) and resident washrooms (−7.0 ACH, 95% CI, −1.3 to −12.7). The absence of ducted air source was associated with decreased ACH in resident rooms (−12.2 ACH, 95% CI, −1.0 to −23.5).

Across 15 CLS, we identified readily actionable targets for improvements to ventilation. Based on our findings, we propose assessment criteria to optimize the performance of existing AHU. Prospective studies evaluating the impact of a standardized approach to improving AHU on safety of CLS residents are needed.

Unnecessary urine cultures contribute to inappropriate antibiotic use, antimicrobial resistance, and Clostridioides difficile infection, particularly when asymptomatic bacteriuria (ASB) is misclassified as infection. We evaluated the diagnostic stewardship impact of an algorithm-based best practice alert (BPA) embedded in the electronic medical record (EMR) to guide urine testing in hospitalized adults.

This prospective quality improvement study was conducted at a 740-bed tertiary care hospital. The BPA triggered when urinalysis with reflex to culture (UACC) was ordered for patients admitted ≥48 hours, guiding clinicians through an algorithm-based ordering workflow. Monthly rates of UACC and pan-culturing were compared between a 12-month pre-intervention period and a 12-month post-intervention period using interrupted time series (ITS) and Mood’s median two-sample test. Gram-negative rod (GNR) bacteremia rates were monitored for safety.

Urine testing decreased from 6.45 to 4.41 tests per 1,000 patient-days (31.6% reduction; P < .01), and pan-culturing decreased from 3.47 to 2.70 per 1,000 patient-days (22.2% reduction; P < .01). ITS showed declining trends both before and after implementation, without significant immediate changes in level or slope following the intervention. CAUTI rates remained stable (0.91 vs 0.82 per 1,000 catheter-days; P = .68), as did rates of gram-negative rod bacteremia (0.47 vs 0.70 per 1,000 patient-days; P = .22). Algorithm adherence averaged 63.9% and increased over time (P < .01). CAUTI cases classified as potential asymptomatic bacteriuria declined from 31.8% to 25.0% (P = .68).

An EMR-integrated, algorithm-based BPA coincided with sustained lower urine testing and pan-culturing rates without adverse safety signals within the context of existing downward trends. Ongoing monitoring is needed to sustain adoption and appropriate use.

Expanded multiplex PCR gastrointestinal panels (GIPs) are routinely ordered to diagnose infectious diarrhea. However, recommendations for repeat GIP testing are limited, resulting in variable testing practices. We evaluated the diagnostic yield of repeat GIP testing within 14 days.

We conducted a retrospective cohort study of adults (age ≥ 18 years) tested with GIPs across 12 hospitals and outpatient centers (2019–2024). We analyzed the first diarrheal episode per patient, excluding cases with invalid/missing results and C. difficile results. Repeat testing was defined as a GIP completed within 14 days of an index GIP, excluding confirmatory testing using the same stool sample. The primary outcome was diagnostic yield (new pathogen detection), and the secondary outcome was pathogen persistence (same pathogen detection).

Among 16,502 patients, 507 (3.1%) underwent repeat GIP testing within 14 days (median interval: 6.3 days; IQR: 2.7–9.8). Only 4.6% [19/415] index-negative patients and 2.2% [2/92] index-positive patients detected new pathogens on repeat testing, with 51% [47/92] index-positive patients demonstrating persistence of at least one pathogen from their initial test. The number needed to test (NNT) to identify one new pathogen was 24 (95% CI: 16–39) tests overall, and 127 (95% CI: 50–455) tests to identify one new pathogen warranting antimicrobial treatment. Most repeat testing (86% [436/507]) was ordered by a different clinician.

Repeat GIP testing within 14 days rarely provided new diagnostic information, highlighting the limited utility of early repeat testing. Institutional policies discouraging repeat GIPs within 14 days may improve diagnostic stewardship.

To support Antimicrobial Stewardship programs (ASPs) as well as the clinical care of patients with infections, we disseminated and implemented a Videoconference Antimicrobial Stewardship Team (VAST) to connect multidisciplinary teams from rural Veterans Affairs (VA) medical centers with geographically distant ID experts. Here, we describe the clinical syndromes discussed and the response to recommendations made during VAST sessions.

Between September 2021 to February 2024, eight ID consultants established VASTs with ten rural VAMCs, holding regularly scheduled videoconference sessions to discuss clinical cases and provide recommendations. Data were collected on patient demographics, clinical syndromes, and recommendations. Acceptance of recommendations within one week of each session was assessed via chart review. Six months after the intervention began, we conducted semi-structured interviews to assess participants’ perceptions of VASTs.

VASTs reviewed 626 cases involving 527 unique patients. Among 763 clinical syndromes discussed, the most common were infections of the respiratory (29%) or urinary tract (21%). Overall, VASTs made 973 recommendations, of which 71% were accepted. Of 570 recommendations related to antibiotics, 459 (80%) were accepted. Among 403 other recommendations, 235 (58%) were accepted. Interviews with participants indicated the importance of building trust and strong interpersonal relationships.

VASTs effectively supported Antimicrobial Stewardship in rural VA medical centers (VAMCs) without local ID expertise. High acceptance rates, particularly for antibiotic-related recommendations, suggest that telehealth-enabled provider-to-provider models enhance stewardship efforts.

Describe the workload associated with using telehealth to support Antimicrobial Stewardship efforts at Veterans Affairs Medical Centers (VAMCs) without local infectious diseases (ID) expertise.

A mixed-methods process assessment to evaluate workload and workflow associated with Videoconference Antimicrobial Stewardship Teams (VASTs).

Rural VAMC champions paired with ID consultants at geographically distant VAMCs to form VASTs.

Total workload estimates were based on time that champions and ID consultants allocated to VAST activities. Clinical Procedural Terminology (CPT) codes were used to estimate the workloads for clinical encounters. Role-based process maps were developed to understand variation in implementation by VAMC.

The average workload that champions and ID consultants allocated to VAST activities was 6.7% (range 1.0%–20.0%) and 8.4% (range 2.0%–12.5%) full-time equivalents (FTEs), respectively. Clinical encounters completed by ID consultants contributed an average of 1.4% (range < 0.01%–2.5%) FTEs to the workload. The average proportion of FTEs required to sustain VASTs was 13.0% (range 3.0%–31.6%). Process maps showed four phases common to each VAST’s workflow: case identification, meeting preparation, team meeting, and documentation. The tasks associated with each phase varied between VASTs. Champions carried out most tasks related to case finding and meeting preparation; the ID consultants completed most documentation tasks.

The distribution of tasks within and among the VASTs indicated opportunities to improve workflow efficiency. Investing <12.5% of the FTE allocated to VA Antimicrobial Stewardship programs to support the time of an ID consultant from another VAMC can help rural VAMCs achieve staffing sustainability.

Antimicrobial Stewardship in the intensive care unit setting is a difficult task due to diagnostic uncertainty and perceived high-risk of poor outcomes in case of delayed or inappropriate treatment. Although novel diagnostics and other strategies have been proposed to improve antimicrobial use, their clinical effectiveness in real-world settings has been suboptimal.

We designed a critical interpretative synthesis of the literature, which allows the combination of quantitative and qualitative studies to revise and critique concepts used in Antimicrobial Stewardship efforts in the ICU setting. We searched the literature in duplicate with a sensitive strategy to identify main concepts, and we developed a main theme and conceptual framework after identifying the main concepts and strategies.

After screening 41,192 titles and abstracts and reviewing 1,335 full-text manuscripts, we selected 29 main manuscripts for this synthesis. We identified that classical concepts, such as the use of broad-spectrum antibiotics followed by de-escalation and the use of biomarkers of infection and novel diagnostics, although with face validity and supported by efficacy studies, carry a high risk of being ineffective in real-world settings. We argue that this discrepancy is due to cognitive biases in antimicrobial decision-making in the ICU setting, including risk-aversion behavior, diagnostic momentum, premature closure, therapeutic momentum, hyperbolic discounting, commission bias, and anchoring bias, among others, which drive intensivists towards overdiagnosis and overtreatment of infection.

Incorporation of the cognitive theory of decision-making in future stewardship efforts is necessary in the ICU setting along with traditional stewardship interventions.

Racial and socioeconomic disparities in COVID-19 have been well documented early in the pandemic, but less is known about the structural and socioeconomic barriers in COVID-19 antiviral prescribing in the later period when therapies became widely available.

Evaluate the socioeconomic factors associated with COVID-19 antiviral treatment outpatient prescription.

Retrospective single healthcare system cohort study.

Three hospital system in Massachusetts USA.

adults diagnosed with COVID-19 or prescribed antiviral therapy in outpatient encounters or emergency departments (ED) between Oct/2022 and Jul/2024.

Among 9,984 patients with COVID-19, 19.5% received antiviral treatment. In adjusted analyses, increasing age (OR 1.03 per year, 95% CI 1.02–1.03), non-White race (OR 1.35, 95% CI 1.14–1.60), and ED encounters (OR 1.15, 95% CI 1.02–1.30) were independently associated with higher odds of treatment. Social vulnerability demonstrated a non-linear relationship: patients with moderate vulnerability had higher odds of treatment, while the most vulnerable group did not.

In this late-pandemic cohort, antiviral prescribing remained low and demonstrated persistent but complex disparities. Social vulnerability showed a non-linear association with treatment, suggesting that patients with the highest vulnerability may face barriers to access despite greater need.