Background: National Healthcare Safety Network (NHSN) data demonstrate substantial declines over time in most hospital-acquired infections (HAIs). In contrast, surgical site infection (SSI) rates have remained largely unchanged, raising concerns regarding the effectiveness of current prevention strategies. Public reporting and pay-for-performance programs primarily focus on Centers for Medicare & Medicaid Services (CMS)–mandated procedures, notably abdominal hysterectomy (HYST) and colon surgery (COLO). It remains unclear whether stagnant SSI rates reflect trends limited to these procedures or represent a broader phenomenon across surgical populations. We sought to determine whether temporal stagnation in SSI rates is confined to CMS-mandated procedures. Methods We conducted a retrospective cohort study using the Duke Infection Control Outreach Network (DICON) database, which includes standardized NHSN SSI surveillance data from participating hospitals. We included hospitals that were continuously enrolled in DICON for the entire study period (January 1, 2020–December 31, 2024). Procedures were excluded if a hospital performed fewer than 100 of a given procedure type in any calendar year. NHSN procedure categories were excluded entirely if <1,000 procedures were performed during the study period. Procedures were grouped as Group 1 (CMS-mandated HYST and COLO) and Group 2 (all other included procedures). Temporal trends in SSI rates were assessed using regression-based models with an interaction term between calendar year and procedure group, adjusting for age, sex, and wound class. Results A total of 64 hospitals met the inclusion criteria. The final dataset included 561,811 total procedures, of which 71,573 (12.7%) were in Group 1 (HYST/COLO) and 490,238 (87.3%) were in Group 2. SSI rates were 3.49 per 100 procedures in Group 1 and 0.77 per 100 procedures in Group 2. (Figure 1) Over the study period, annual SSI rates did not change significantly in Group 1 (annual rate ratio [aRR] 1.03; 95% CI 0.99–1.06, p=0.06) or Group 2 ([aRR] 1.01; 95% CI .98-1.03). (Figure 2) Moreover, there was no significant difference in annual SSI rates between COLO/HYST and other procedures (difference in annual trend aRR 0.98; 95% CI 0.94–1.02; p=0.25). Discussion In this multicenter analysis, stagnation in SSI rates was observed among both CMS-mandated procedures and non-mandated surgical procedures, suggesting that stable SSI rates reflect broader challenges in SSI prevention rather than artifacts related to surveillance or reporting. These findings highlight the need for novel, risk-adjusted prevention strategies.

Background: Many laboratories have shifted from traditional culture-based to molecular panel diagnosis of gastrointestinal (GI) pathogens for a broad array of reasons including simplicity and rapidity. The Portland VA Health Care System (VAPORHCS) implemented the Biofire® Film array® GI pathogen panel (Biofire GI panel) 05/2024. In 04/2024, a recall alert was issued regarding increased risk of false positive norovirus results alongside a recommendation to confirm positive results by another method. The aim of this quality improvement project was to evaluate the false positive rate for norovirus of this assay. Methods: We used microbiology laboratory records to identify all norovirus positive results on the Biofire GI panel from 05/2024-09/2025. Chart review was performed to determine confirmatory norovirus test results, testing location (outpatient, inpatient, or emergency department), compatible clinical symptoms (acute nausea/vomiting/diarrhea), and the presence of other positive stool testing results. False positive was defined as discrepant Biofire GI panel (positive) and dedicated norovirus PCR (negative) results on the same sample. Result: We identified 39 initial positive tests on the Biofire GI panel from 38 unique patients. One test was excluded due to specimen processing error on the confirmatory test, leaving 38 tests for analysis. Of these, 13 (34%) were confirmed as positive by single-plex PCR corresponding to a false positive rate of 66%. False positive rate stratified by test location are shown in Figure 1. Compatible symptoms stratified by test results are shown in Figure 2. Of the true positive group, 11/13 (85%) had diarrhea < 5 days compared to 6/25 (24%) in the false positive group (p<0.001). Similarly, in the true positive group, 11/13 (85%) of patients had nausea/vomiting compared to 5/25 (20/%) in the false positive group (p<0.001). An alternative enteric pathogen was identified in 8/38 (21%) cases. Conclusion: We found an alarmingly high rate of false positive norovirus results on the Biofire GI panel at our center, which is higher than previously reported. True positive tests were more likely to be accompanied by those that fit with typical symptoms. Positive norovirus results from the Biofire GI panel should be interpreted with caution as is recommended by the manufacturer, particularly in absence of a compatible clinical syndrome.

Objective: To address the recurrent contamination of handwashing sinks with Pseudomonas aeruginosa (PA) in the Pediatric Intensive Care Unit (PICU), evaluate the PA elimination efficacy of different disinfectants and disinfection methods, and optimize disinfection strategies to prevent PA colonization and transmission, thereby reducing the risk of healthcare-associated infections (HAIs)? Methods: Nine handwashing sinks in the PICU (August–December 2024) were selected, meeting the criteria of three consecutive positive PA detections, usage frequency ≥20 times/day, and no prior special disinfection interventions (excluding those with recent pipe replacement or structural damage). They were divided into three groups (3 sinks per group). Three disinfectants were prepared: 500 mg/L chlorine-containing disinfectant, 0.5% benzalkonium chloride disinfectant, and 75% ethanol stock solution. Three disinfection methods were applied: rinsing method (disinfectant flushing for 1 minute twice daily at 5 L/min), soaking method (full coverage soaking with disinfectant for 30 minutes every morning followed by flushing), and slow-release soaking method (slow injection of disinfectant into the trap for 30-minute soaking, 10-minute standing, then flushing at 2 L/min). Samples were collected from the overflow outlet, drain, and other sites before disinfection, 1 minute after disinfection, and 24 hours after disinfection. Colony counting was performed using the pour plate method, PA was identified via the VITEK 2 system and mass spectrometry, and statistical analysis was conducted with SPSS 26.0 (α=0.05). Results: 75% ethanol showed the best immediate effect (colony count <0.1 CFU/cm² and PA detection rate 0% 1 minute after disinfection, P<0.001) but PA reoccurred at 24 hours. Chlorine-containing disinfectant performed stably (colony count reduced to 0.2 CFU/cm², PA detection rate 0%, P=0.002) with the optimal 24-hour bacteriostatic effect. Benzalkonium chloride had weak efficacy (colony count reduced to 5.0 CFU/cm², PA detection rate 33.3%). The soaking method and slow-release soaking method were significantly more effective in biofilm removal than the rinsing method (e.g., no PA detected with chlorine-containing disinfectant soaking method and <10% recurrence rate at 24 hours, compared to 66.7% PA positivity rate with the rinsing method at 24 hours), and the soaking method was more operable. Conclusion: For PA-contaminated handwashing sinks in the PICU, the chlorine-containing disinfectant soaking method has the best comprehensive effect, combining strong bactericidal power, good long-term bacteriostatic effect, and high operability. It is suitable as a routine disinfection scheme to prevent PA colonization in the ward, providing support for HAI prevention and control. Future research can explore more disinfection methods for ward sinks.

Background: Antimicrobial resistance (AMR) is a growing global health threat, yet surveillance systems remain heavily centered on clinical reporting and often overlook environmental transmission pathways. Urban rivers receiving mixed municipal, hospital, and agricultural inputs may act as important reservoirs and dissemination routes for antibiotic resistance genes (ARGs), particularly in resource-limited settings. Understanding spatial patterns of environmental resistomes is essential for advancing One Health–informed AMR surveillance. Methods: We conducted a longitudinal, multi-site investigation of ARG occurrence along the Cuautla River, an urban watershed in Morelos, Mexico, serving the resource-limited city of Cuautla. Surface water samples were collected across six locations spanning urban upstream (L1-2), urban core (L3-5), and urban downstream zones (L6) (Figure 1). Targeted droplet digital PCR (ddPCR) was used to quantify relevant ARGs, including Gram-positives (mecA and vanA), Gram-negatives beta-lactamases (CTX-M and SHV), AmpC-type β-lactamase (CMY), and Carbapenemase (KPC, NDM, VIM, IMP, and OXA-48), tetracycline (tetW) and Polymyxin-resistant (MCR-1). Physicochemical parameters and fecal indicator bacteria were measured concurrently to contextualize microbial contamination. Spatial and temporal trends in ARG abundance and composition were evaluated using non-parametric statistical analyses. Results: ARGs were widely detected across the watershed, with particularly high abundances of tetW, CMY, TEM, and multiple Gram-negative carbapenemase genes, including KPC, OXA-48, and VIM. The plasmid-mediated colistin resistance gene mcr-1 was also detected at multiple sites, highlighting the environmental presence of resistance determinants associated with last-resort antimicrobials (Figure 2). ARG abundances generally increased from urban upstream to urban downstream locations, likely reflecting cumulative inputs from domestic wastewater, healthcare facilities, and densely populated areas. Although ARG loads peaked within the urban core, elevated resistance signals remained detectable in downstream urban edge regions (Figure 3). In contrast to largely compliant physicochemical conditions, fecal indicator bacteria revealed pervasive microbial contamination across urban sites. Conclusions: Our findings demonstrate extensive resistome contamination within an urban river system, encompassing both environmental and clinically important ARGs. The spatial accumulation of resistance signals downstream and the detection of colistin resistance genes underscore the role of river ecosystem as conduits linking human activity to broader environmental AMR dissemination. These results highlight the need to integrate environmental water surveillance into AMR monitoring frameworks and support a One Health approach that connects wastewater management, antibiotic stewardship, and public-health protection in resource-limited settings.

Background: Acute bacterial rhinosinusitis (ABRS) is a common, often self-limited condition that frequently leads to inappropriate antimicrobial prescribing in children. Continued reliance on the 2013 American Academy of Pediatrics (AAP) sinusitis guidelines and limited awareness of newer recommendations—particularly those supporting shorter treatment durations—have contributed to antibiotic overuse. As part of an enterprise-wide antimicrobial stewardship initiative, an intervention was implemented to support outpatient pediatric clinicians in identifying children most likely to benefit from antibiotics and in prescribing a 5-day course of guideline-concordant therapy consistent with the 2024-2027 AAP Red Book. We evaluated the impact of this intervention on prescribing practices and clinical outcomes. Methods A retrospective study was conducted among pediatric outpatients diagnosed with uncomplicated ABRS between January 1 and December 1, 2025 at an urban primary care pediatrics clinic within a large health system. The intervention consisted of a brief, targeted educational lecture delivered at a division meeting by pediatric antimicrobial stewardship leadership (pharmacist and physician), emphasizing updated guidance and promoting use of a sinusitis Epic order set. A one-page summary infographic was also distributed for reference. Data were extracted using Epic SlicerDicer and included patient demographics, clinical presentation, antibiotic selection and duration, use of the sinusitis order panel, and clinical outcomes. Outcomes before and after the intervention (May 14, 2025) were compared. Results A total of 99 pediatric patients with uncomplicated ABRS were included, with 55 treated before and 44 after the intervention. Use of the sinusitis order panel increased from 16% to 39% of encounters. The proportion of patients meeting diagnostic criteria for ABRS decreased slightly from 95% to 91%. Prescribing of 5-day antibiotic courses increased from 11% to 34%. There were no significant differences in prescribing provider type, antibiotic selection, or clinical outcomes—including Clostridioides difficile infection, return outpatient visits, or hospital admissions related to ABRS within 30 days—between patients receiving 5 versus <5 days of antibiotics (p<0.05). Conclusions A single, brief educational intervention paired with promotion of an Epic order set and summary infographic increased prescribing of shorter (5-day) antibiotic courses for pediatric ABRS without adversely affecting short-term clinical outcomes. Further studies are needed to assess the durability and long-term impact of this intervention on prescribing behavior.

Behavioural design processes have proliferated in recent years across a diverse set of fields including policy, product development and health. However, this diversity of perspectives also increases ambiguity regarding which (and when) processes should be enacted, which hinders research and practice across fields. This drives two research questions: (1) How are behavioural design processes currently framed, described, and enacted? and (2) How can we consistently understand commonalities and differences across behavioural design processes? In response to these questions, we adopt a critical interpretive synthesis (CIS) approach, reviewing 12 processes from academic and practitioner sources selected through purposive sampling and analysed using a theory-informed coding protocol. Through interpretive synthesis, we re-characterise behavioural design in terms of an ecosystem of distinct but complementary processes rather than its typical presentation in fixed sequences of steps. This increases behavioural design’s ability to respond to different degrees of uncertainty and dynamism in the problem and solution as well as its ability to reflect diverse assumptions about uncertainty, iteration, outcomes and practitioner capability. This research supports an important and developing interdisciplinary area by bringing design process into a design science research context through which many of these topics can be further discussed and developed.

While malaria transmission in coastal East Africa is strongly shaped by climatic variability, few studies examine long-term interactions in rapidly urbanizing settings. This study evaluated the impact of climate and seasonal trends on malaria incidence in Dar es Salaam, Tanzania (2014–2024). Monthly cases and meteorological data were analyzed using seasonal-trend decomposition (STL) and generalized additive models (GAMs) to quantify nonlinear and lagged climatic associations. Over the decade, malaria incidence declined sharply from >130 cases per 10,000 in 2014 to <30 by 2023. However, strong seasonal peaks persisted, with STL revealing consistent annual surges during April–June following the rainy season. GAM analysis identified rainfall as the dominant climatic driver, demonstrating significant 1- and 2-month lagged effects (p < 0.001). Daytime (1-month lag) and night-time (2-month lag) temperatures showed non-linear associations, peaking in incidence at optimal mosquito-development temperatures (~30–31°C). Despite substantial incidence declines, transmission remains highly climate-sensitive. Driven primarily by lagged rainfall and temperature effects rather than current-month conditions, these dynamics underscore the urgent need for climate-informed early warning systems and targeted seasonal interventions in coastal urban environments.

Title: Hospital-onset influenza and RSV: Impact of Infection Prevention Efforts During the COVID-19 Pandemic Authors: Emily Schmitz, MD, MPHa Laura Anderson, RN, MPH, CICb Daniel Shirley, MD, MSa,b,c Affiliations: University of Wisconsin School of Medicine and Public Health, Madison, WI UW Health, Madison, WI Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI Objective: To quantify and characterize hospital-onset influenza and respiratory syncytial virus (RSV) cases, pre- and post- COVID-19 pandemic. Design: Retrospective cohort study from January 1, 2018 - December 31, 2024. Setting: This study was conducted at a large urban Midwestern tertiary-care hospital system. Participants and Interventions: The Infection Prevention team reviewed the electronic medical records (EMR) of patients who were admitted > 48 hours and subsequently tested positive for influenza and/or respiratory syncytial virus (RSV). Incubation periods for each virus were determined based on Centers for Disease Control and Prevention (CDC) guidance and literature review. Hospital-onset was defined as a positive test three or more days after admission for influenza and six or more days after admission for RSV. Patients were excluded if a positive test did not meet these criteria or was completed at least 1-week prior to admission. Clinical data including medical comorbidities, anti-viral administration, vaccination and immunocompromised status were collected from the EMR. Hospital-associated influenza and RSV data were taken from the Wisconsin Communicable Disease Surveillance Data. Results Forty-nine patients met criteria for hospital-onset influenza infection, and 44 (89%) were symptomatic. Twenty-one (43%) patients required the intensive care unit (ICU) and mechanical ventilation during their hospitalization. The majority of patients (92%) received anti-viral therapy (oseltamivir). Nineteen patients (39%) were immunocompromised. A total of 30 (61%) were vaccinated against influenza for the season. Three patients died during their hospitalization, for an in-hospital mortality rate of 0.06%. Nineteen patients met criteria for hospital-onset RSV infection and 18 (95%) were symptomatic. In patients with RSV, 6 (32%) required the ICU and mechanical ventilation during their hospitalization. Only 5 patients (26%) received antiviral therapy for their RSV infection. Compared to influenza, hospital-onset RSV was associated with a higher in-hospital mortality rate (n=3, 16%). There were no hospital-onset influenza or RSV cases from April 2020 through March 2022, which coincides with the COVID-19 pandemic. Cases increased with 12 cases of hospital-onset influenza and 6 cases of hospital-onset RSV in 2024, which were similar to pre-pandemic rates. Discussion Hospital-onset influenza and RSV lead to significant morbidity and mortality. These preventable infections also put healthcare workers and other patients at risk. Data suggest that enhanced infection prevention efforts during the COVID-19 pandemic mitigated the number of hospital-onset cases of influenza and RSV. During periods when influenza and RSV rates are high, enhanced infection prevention efforts are likely warranted to prevent hospital-onset cases.

Background: Current US healthcare-associated infection (HAI) surveillance misses many serious nosocomial infections. Electronic identification of hospital-onset sepsis using CDC Adult Sepsis Event (ASE) criteria could expand the breadth and efficiency of HAI surveillance, but little is known about the preventability of these events. Methods: We identified hospital-onset sepsis events on hospital day ?4 using updated ASE criteria amongst adults admitted to 9 hospitals in Massachusetts, 2021-2023. We randomly selected 224 sepsis events to adjudicate infection probability and source (50% academic, 50% community hospitals) and then analyzed 100 confirmed infections for preventability using a 6-point Likert scale. Two physicians reviewed cases for infection source, following joint review and discussion of the first 25 cases with two senior physicians to standardize approach. All preventability assessments were classified by consensus amongst three physicians. Results: Amongst 224 hospital-onset sepsis events, 100 (45%) had definite or probable infection, 82 (37%) had possible infection, and 42 (19%) had no infection. Most sepsis events were due to respiratory (47%), bloodstream (16%), abdominal (13%) and urinary (9%) infections (Figure 1). Only 11 events were CMS-reportable NHSN HAIs (mostly central-line associated bloodstream infections and catheter-associated urinary tract infections). Crude inpatient mortality for hospital-onset sepsis cases was 35%. Amongst 100 cases assessed for preventability, 30% were judged potentially preventable (Figure 2), most commonly due to lapses in managing established infections (41%) including delays in source control, microbiologic testing, antimicrobial administration, imaging, and subspecialty consultation. Gaps in nosocomial respiratory infection prevention measures were also common (36%) including insufficient oral care, lack of dysphagia management, and failure to mask (Figure 3). Lapses in traditional device-related HAI prevention bundles were uncommon (7%). Some hospital-onset sepsis events may have been preventable with better general medical care (17%), including earlier recognition and management of non-infectious contributors to physiologic deterioration (e.g., earlier diuresis to optimize respiratory reserve among patients at risk for aspiration, proactive bowel management to prevent stercoral colitis and downstream infectious complications). Conclusions: Hospital-onset sepsis events identify serious, often fatal infections, many of which are potentially preventable. Opportunities extend beyond current HAI prevention bundles and include the need for more timely recognition and management of established infections to prevent progression to sepsis, introducing measures to prevent nosocomial respiratory infections, and improving general inpatient medical care. Incorporating hospital-onset sepsis surveillance into infection prevention and quality improvement programs could help identify actionable steps to improve the safety and quality of inpatient care.

Background: Outpatient parenteral antimicrobial therapy (OPAT) is a common approach to treating complex infections, offering benefits of higher patient satisfaction, reduced risk of hospital-acquired infections, and lower healthcare costs. However, limited information exists regarding how OPAT is delivered across U.S. healthcare systems. We sought to understand OPAT practices and identify facilitators and barriers to OPAT delivery at Veterans Affairs (VA) medical centers (VAMCs), which constitute the largest integrated healthcare system in the U.S. Methods: We conducted a national survey of VAMCs between January-April 2025. OPAT providers were invited via email to complete an online Qualtrics survey. Topics included care delivery, patient monitoring, and perceived challenges to safe, effective OPAT care. Data were summarized using descriptive statistics. Results: Of 139 surveys, 106 (76.3%) were completed and analyzed. Most VAMCs offered OPAT (78/106; 73.6%). Among those, 60/78 (76.9%) designated OPAT providers to monitor and manage care, often Infectious Disease (ID) physicians (54/60; 90.0%) and ID pharmacists (44/60; 73.3%). Dedicated time for OPAT care activities varied by site and role. Guidelines for OPAT care were reported at 45/78 (57.7%) VAMCs, typically outlining eligibility criteria as well as protocols for patient monitoring and follow-up. Generally, VAMCs required ID consultation prior to discharge and discharged 1-10 patients on OPAT per month, most of whom were followed by ID providers. OPAT-related outcomes were measured by about half of VAMCs (40/78; 52.6%); adverse events were most frequently measured. OPAT delivery extended beyond VAMCs through referrals to outside healthcare systems and collaboration with contract infusion pharmacies and home health agencies (Table 1). Respondents noted challenges to providing safe OPAT care, including dedicated time, communication with organizations outside the VA, and timeliness of labs (Figure 1). Conclusions: While individual VAMCs varied in delivery practices, key elements across programs included designated providers and defined OPAT care components. Challenges were driven by fragmented care, which hindered communication and coordination. Expanding VAMC capacity to provide OPAT and monitor patients may streamline communication, delivery, and continuity. A process map for referrals outside the VA may help designate roles and responsibilities for monitoring and providing OPAT care.

Late HIV diagnosis increases morbidity and mortality. In this retrospective cohort study on the national HIV register, we analysed risk factors for late HIV diagnosis among newly registered people living with HIV (PLWH) between 2008 and 2023, using the updated definition. Of 2683 PLWH registered, 1813 (67.6%) were newly diagnosed with CD4+ T-cell count available ≤90 days for 1572 (86.7%). Eighty-seven of the 609 (14.3%) individuals with CD4+ T-cell count <350/μL had recent infections and were reclassified as non-late. Of the newly diagnosed, 50.3% were diagnosed late. Multivariable analysis identified higher age as an independent risk factor for late diagnosis (adjusted OR 1.42 per ten years, 95% CI 1.30–1.56). Of the Finnish-born, females had lower odds than males (aOR 0.59, 95% CI 0.39–0.88). Asian-born (aOR 6.83, 95% CI 3.49–13.35) and African-born females (aOR 3.26, 95% CI 1.58–6.73) had significantly higher odds than Finnish-born females. In urban municipalities, men who have sex with men had lower odds than individuals with heterosexual transmission (aOR 0.55, 95% CI 0.40–0.76). Higher age was the most important factor for increasing the proportion of late diagnoses. We recommend enhanced testing and risk awareness for older adults and migrants from high-prevalence countries.

Background: During a measles outbreak in the United States in 2025, health care settings were on high alert for patients who may have been exposed to or infected with this disease. When an infection is found, contact tracing investigations are extensive and require significant labor. Identify, Isolate, Inform (III) has become a standard tool for special pathogen preparedness. Our facility implemented an electronic medical record (EMR) alert for patients reporting fever and rash. The objective of this work is to compare and contrast our experience in drill vs clinical practice. Methods: Setting. Denver Health is an acute-care safety net hospital with both adult and pediatric emergency departments, sharing a common security checkpoint for entrance, and a check in and arrival space before patients are triaged into individual waiting rooms. Drill. In March 2025, Denver Health conducted a drill to test the III process in the pediatric emergency department and urgent care center (PEDUC) where care was provided for a mock patient with fever, rash, and cough. Time to masking and time to isolation were collected by a drill observer. Clinical practice. In April 2025, an infant with recent international travel presented to the PEDUC with cough, fever, and rash and was subsequently diagnosed with measles by PCR. Time to isolation was collected via time stamps in the EMR. Results: During the drill, fever and rash were documented, and the alert fired appropriately. The mock patient was masked within six minutes of entry and roomed in a negative pressure room within nine minutes of entry. During clinical practice, rash was documented, but the patient was afebrile at triage, and the EMR alert did not fire. The patient spent 62 minutes in the waiting room before being roomed. Contact tracing involved individuals in both the adult and pediatric emergency departments due to the shared airspaces. In total, 149 patients were identified as contacts and were notified of the exposure by public health. No transmission was identified. Conclusions: Despite a recent successful drill in the PEDUC, when a patient presented with measles, there were challenges with identification and isolation, as well as structural limitations within the facility and gaps with technology aiding the early identification of patients at risk. Having a real-life situation resulted in an extremely large contact investigation and juxtaposed the recent successful drill, highlighting the need to continue performing “no notice drills” and work on improving each facet of preparedness.

Background: Respiratory Syncytial Virus (RSV) is a leading cause of infant hospitalizations in the United States and is particularly devastating to infants 6 months and younger. Maternal RSV vaccination given more than two weeks before delivery and early infant nirsevimab administration can provide protection against severe illness in this vulnerable population. Objective: To evaluate uptake of, and barriers to, RSV immunization among infants admitted to the hospital with RSV infection in a large healthcare system. Additionally, clinical outcomes between infants who did and did not receive any RSV protection were compared. Methods: This was a retrospective cohort of infants ? 6 months old hospitalized in a large multi-state healthcare system from November 2024 to January 2025 with a positive RSV test within 7 days prior to or during admission. Patients were identified using an electronic health record report and chart review was performed to obtain data on RSV immunization and clinical outcomes. Infants born outside of our healthcare system where information on RSV immunization was lacking were excluded. Infants were classified as protected if either 1) maternal RSV vaccination was given more than two weeks before delivery or 2) the infant received nirsevimab prior to the onset of RSV infection. All others were classified as unprotected. Clinical outcomes including length of stay, ICU admission, and mechanical ventilation were compared between groups. Identification of barriers to RSV immunization were attempted. Result: Of 152 infants admitted with RSV, 103 were born in our hospitals and included. 17 (16.5%) patients were considered protected (8 with maternal vaccination; 9 infant nirsevimab administrations). Patients in both groups were predominantly male and either Non-Hispanic White or Hispanic. Compared to unprotected patients, protected patients had significantly fewer ICU admissions (0% vs 28%, p = 0.03) and shorter median length of stay (1 vs 2 days, p=0.004). There was no difference between groups in rates of mechanical ventilation or death. Among unprotected patients, chart review most often showed no documentation of any RSV immunization discussions (75.6%), family declined treatment (12.8%), and infants becoming ill before nirsevimab could be administered despite willingness to eventually receive it (11.6%). Post-RSV infection, an additional 12% of unprotected patients received nirsevimab. Conclusion: Unprotected infants were more likely to experience negative clinical outcomes, specifically more ICU admissions and longer hospitalizations. Opportunities exist to improve RSV provider and family education and implement interventions to facilitate discussion and administration of RSV prophylaxis.

Background: Multiplex syndromic polymerase chain reaction (PCR) panels can rapidly identify pathogens in patients with diagnosis of pneumonia, but they may also detect colonizing bacteria, which can lead to diagnostic uncertainty. Their utility in sputum samples remains unclear, as most evidence comes from higher-quality bronchoscopy specimens. To ensure these tests are used in scenarios with the greatest clinical impact, such as when results can be returned quickly and guide treatment, we developed a clinical decision support tool. The tool restricts ordering of multiplex pneumonia PCR panel on sputum samples to patients with severe illness or immunocompromise. Methods: The study was conducted at a New York City hospital system. Beginning in December 2024, the pneumonia PCR panel decision support tool was implemented and restricted ordering on sputum samples to patients who were admitted to the intensive care unit (ICU), prescribed vasopressors, required at least high flow nasal cannula for supplemental oxygen, had solid organ or hematopoietic transplant, received Gram negative coverage with meropenem or broader for 48 hours without improvement, and/or infectious diseases or pulmonary attending consult recommendation. We analyzed the total number of sputum pneumonia PCR panels and associated positivity rates prior to and after implementation of the decision support tool during quarters 1 through 3 of 2023, 2024 and 2025. Results: After intervention implementation, the overall number of sputum pneumonia PCR panels ordered decreased by 34%. At $200 per PCR panel, this represents a cost savings of at least $208,000. The greatest change was on non-ICU inpatients, where the total decreased from 1267 in 2024 to 504 in 2025 (60%, Figure 1). The emergency department had a decrease from 266 in 2024 to 125 in 2025 (53%). There was minimal change in PCR panel usage in the ICU and outpatient, which are areas not targeted by the intervention. The positivity rate was consistent over the three years (70-75%). Most sputum PCRs detected multiple bacterial organisms (57-70%, Figure 2a) and 5-11% of samples detected bacteria at a quantity of only 10^4, with or without viral co-infection (Figure 2b). After reviewing post-implementation quarter 1 2025 data, broad Gram-negative coverage was removed as a testing criterion since it was selected frequently (32%) but not accurately (10% accuracy). Conclusion: Implementation of a clinical decision support tool in Epic led to more appropriate diagnostic stewardship of the multiplex pneumonia PCR, improving care and reducing costs. Future interventions will target improving stewardship in the ICU.

Background: We describe an investigation of a cluster of eight Corynebacterium amycolatum sternal surgical site infections (SSIs) that occurred among cardiac surgery patients from February to October 2025. Although C. amycolatum is a member of the skin microbiota, clinically significant infections caused by this organism may occur in cardiac surgery patients. Methods: The investigation included retrospective reviews of SSIs, clinical cultures and medical records, surgical observations, and operating room (OR) assessment. Line lists of surgical case criteria and infection prevention practices were created to assess common factors among cases (e.g., staffing, instrumentation, equipment, skin preparation and antisepsis, nasal decolonization, antibiotic protocols, and closure). Whole genome sequencing of isolates was performed and analyzed using SNIPPY for single-nucleotide polymorphism (SNP)-based phylogenetic analysis. Results: Phylogenetic analysis indicated isolates from five of eight case patients who had cardiac surgeries occurring over a six-week period from February to April 2025 were genetically related (?7 SNPs across the genome), suggesting a common source of infection. These five isolates were ceftriaxone, meropenem, and penicillin resistant. The other three case patient isolates were unrelated (<3181 to <15,000 SNPs); two were ceftriaxone, meropenem and penicillin resistant (one also doxycycline intermediate resistant), and the third penicillin resistant. Use of sternal tape for closure was identified as a recent practice change. Four of five genetically related cases involved the same surgeons and suture tape for sternal closure (wire for all other cases). Sternal tape was discontinued with three cases occurring afterwards. Seven patients completed chlorhexidine gluconate bathing and nasal decolonization. Hair was removed in the OR with reusable surgical clippers. All received the same skin antiseptic, and antibiotic prophylaxis was appropriate. No trends were identified in instrument or equipment use. Broad infection control measures were implemented, including surgical clipper replacement, OR cleaning and ultraviolet light disinfection, headlamp cleaning, and environmental repairs. Leadership was engaged through frequent meetings and audits. Infection control practices such as minimizing OR traffic, double gloving, glove changes, and strict adherence to hand hygiene and attire were reinforced. Two of eight cases occurred after these recommendations were completed but were not genetically related to the primary cluster. Conclusion: We describe a cluster of invasive C. amycolatum sternotomy SSIs. Only two genetically unrelated cases of C. amycolatum occurred following infection control investigation and interventions, underscoring the effectiveness of a comprehensive, multidisciplinary approach. This organism has rarely been reported as a cause of SSIs and may be an emerging pathogen.

Introduction: Surgical site infections (SSI) account for 20% of all healthcare-associated infections (HAIs). SSI are associated with increased patient mortality, morbidity, length of hospitalization and risk of readmission with an associated total healthcare cost of $3.3 billion annually. Of the reported SSIs, colorectal (COLO) surgeries have been among the highest risk procedures. A crucial element to prevent HAI is the accurate identification of true events. This allows for comparison of facility-specific performance metrics with peer groups and the development and implementation of targeted interventions to reduce SSI burden. In this abstract, we assessed the impact of multidisciplinary intervention to accurately identify, and document visualized infections on SSI rates and Standardized Infection Ratios (SIR) at a tertiary care teaching facility. Methods: A quasi-experimental study was conducted from 02/01/2024 to 06/30/2025 to improve the accuracy of operative note documentation of visualized infections. Indicators to evaluate possible SSI events included readmission(s), chief complaint, surgical logs, diagnostic codes, antibiotic use, lab/culture data and keywords that may indicate a surgical site infection. Subsequently identified procedures were evaluated by the Surveillance Infection Preventionist team, the Medical Director of Infection Prevention, and the Surgical Quality Officer. If indicated, the operating surgeon was consulted to determine whether visualized infection criteria were met and/or correctly documented. Turnaround time for case reviews was determined. We compared the observed SSI rates and Standardized Infection Ratios (SIR) with the uncorrected rates and SIR accounting for the clarified events. Results: Of 1,142 procedures, 55 were initially identified as COLO SSI. After multidisciplinary review, 12 (22%) of the 55 were found to be present at the time of surgery (PATOS). An additional two events (4%) were determined to not meet SSI criteria. The table summarizes the results of the review process showing a statistically significant correction in SSI event rates from 4.82/100 surgeries to 3.59/100 surgeries (p<0.0001). The turnaround time from identification of a potential SSI event to final determination was four days (range: 1-6 days). Conclusion: Surgical site infection events are critical quality outcome measures for both regulatory and reputational agencies. However, the misclassification of SSIs, such as observed in our study, can create a misleading picture of institutional performance, divert attention from preventable cases, and undermine confidence in surveillance systems. Our multidisciplinary approach ensures a more accurate identification of SSI events. This method can serve as a model for enhancing surveillance accuracy and reliability across healthcare settings.

Background: Clostridioides difficile Infection (CDI) is one of the leading causes of hospital-acquired infections. The Veterans Health Administration launched a national CDI prevention initiative in 2012 that bundled core practices such as environmental cleaning, strict hand hygiene, and contact precautions. In contrast to prior studies which have noted a decline in CDI rates during the COVID-19 pandemic, rates of hospital-onset (HO)-CDI increased at our Veterans Administration Hospital, and we sought to address this issue with a multi-pronged approach. Methods: We assessed multi-modal approaches implemented to reduce HO-CDI rates at Veterans Affairs North Texas Health Care System (VANTHCS), a large, academic VA medical center from 2021 to 2025. This approach included laboratory changes to CDI testing, updates to infection prevention practices, and antimicrobial stewardship program (ASP) rounds for prospective audit and feedback for antibiotics (including those considered high-risk for CDI by the National Healthcare Safety Network). Our primary objective was to assess the impact of these interventions on the incidence of HO-CDI, comparing HO-CDI rates before (Q2 2020–Q4 2022) and after (Q2 2023–Q3 2025) their implementation. HO-CDI was defined as a LabID event collected from an inpatient location < 3 days after admission (i.e., on or after hospital day 4), and rates were reported as number of HO-CDI/10,000 bed days of care (BDOC). Cases were extracted from the Computerized Patient Record System. Results: In October 2021, VANTHCS switched from a standalone nucleic acid amplification test (NAAT) to a 2-step algorithm wherein an initial NAAT was reflexed to a toxin immunoassay if positive. The Infection Prevention and Control Program developed standard operating protocols for room cleaning and disinfection, and hand hygiene was reinforced. In February 2023, the facility ASP implemented thrice-weekly rounds. Institutional antimicrobial guidelines were developed for common infections, and educational presentations were delivered to providers, using illustrative cases to highlight key stewardship principles. ASP team members audited 2,282 patient charts from April 1, 2023, through September 30, 2025. Interventions were made for 1,215 (53%) patients, and prescribers accepted 972 (80%) recommendations. Common interventions consisted of either antibiotic discontinuation or de-escalation in 74% of patients. Mean quarterly high-risk CDI antibiotic use declined from 95 to 71 per 1,000 BDOC (25%, p<0.01), and HO-CDI rates declined 59% from 3.81 (pre) to 1.55 (post) infections per 10,000 BDOC. Conclusion: A multipronged approach of reinforcing IPC practices, 2-step testing, and targeted feedback for antibiotics use led to significant decreases in HO-CDI rates.

Background: Patients undergoing hepato-pancreato-biliary (HPB) surgery routinely need central venous access for chemotherapy or parenteral nutrition. Common postoperative complications of HPB surgeries include cholangitis and transient bacteremia from biliary tract manipulation. Previous studies have suggested that the National Healthcare Safety Network (NHSN) criteria that designate bacteremia secondary to infections such as cholangitis, may be too strict to account for these situations, resulting in central line associated bloodstream infection (CLABSI) misattribution. Methods: This retrospective study evaluated bacteremia events within 30 days of an HPB surgical procedure among patients ≥ 18 years old at a large academic medical center in the United States. The study period included January 1, 2024 through October 31, 2025. HPB procedures were identified using operative codes mapped to HPB surgeries by NHSN with bacteremia cases identified electronically. CLABSI cases, as established by NHSN criteria, underwent manual chart review to understand the clinical context. Results: There were 1,143 HPB surgeries within the study period. Bacteremia was detected in 35 of them (3.1%). Five of these were ruled in as CLABSI. CLABSIs occurred at an average of 9.6 days postoperatively and 7.6 days after central line placement or access. CLABSIs were due to Enterococcus faecalis, Candida krusei, Prevotella species, Klebsiella oxytoca, and Staphylococcus aureus. Three of the CLABSIs had clinical evidence of cholangitis, but imaging findings were insufficient to meet NHSN criteria for an intraabdominal infection. These cases included transient bacteremia within 24 hours of biliary manipulation (drain placement for a portobiliary fistula, n=1, and drain capping, n=2). The other two CLABSI cases did not undergo biliary manipulation during their hospitalization and had no clear evidence of secondary infection. Conclusion: A substantial number of CLABSIs in HPB surgical patients may represent misattribution. Consideration to the unique infection risks of HPB surgical patients such as transient bacteremia related to drain placement and exchange could minimize CLABSI misattribution in this patient population. Ellsworth, M. G., Ausborn, V., Patel, B., Chang, P., & Ostrosky-Zeichner, L. (2023). 2419. Increasing Misattribution of Bacteremia as CLABSIs by NHSN Definitions: A Tertiary Care Center Perspective. Open Forum Infectious Diseases, 10(Suppl 2), ofad500.2039. https://doi.org/10.1093/ofid/ofad500.2039

Background: Inappropriate urine culture ordering in hospitalized patients with indwelling urinary catheters contributes to unnecessary antibiotic exposure and increased risk of catheter-associated urinary tract infections (CAUTI). Urine Culture Stewardship Interventions have emerged as strategies to reduce unnecessary urine culture testing and downstream antibiotic use; however, the magnitude of their impact across clinical settings remains incompletely characterized. Methods: We conducted a scoping review following PRISMA-ScR guidelines to identify studies evaluating urine culture stewardship interventions in hospitalized adults (≥18 years) with indwelling urinary catheters. A systematic literature search was performed in PubMed, Cochrane Library, Web of Science, and Scopus from inception through June 2025, using predefined terms related to indwelling urinary catheters, urinary tract infections and CAUTI, urine culture and diagnostic stewardship, antibiotic use, and catheter management strategies. Interventions included reflex urine culture protocols, catheter replacement prior to specimen collection, educational initiatives, and multicomponent stewardship bundles. Outcomes of interest were urine culture utilization, CAUTI rates, and antibiotic utilization. Data were extracted independently by two reviewers using Covidence. Results were synthesized descriptively, and ranges of relative change were calculated by the review authors when pre- and post-intervention rates were explicitly reported. Results: Conclusion: Urine culture stewardship interventions in hospitalized adults with urinary catheters are consistently associated with meaningful reductions in urine culture utilization and CAUTI rates, with variable but generally favorable effects on antibiotic use. Education-based and reflex urine culture strategies, particularly when embedded within multicomponent stewardship bundles, appear most frequently studied and effective. These findings highlight the potential of diagnostic stewardship as a key component of infection prevention and antimicrobial stewardship efforts, while underscoring the need for standardized outcome reporting and to better quantify downstream clinical impact.