Background: In February 2024, Prisma Health, a 17-hospital healthcare system, changed the reflex urine culture criteria to ≥10 white blood cells (WBC) and rejecting cultures if ≥10 epithelial squamous cells in urinalysis (previously included leukocyte esterase and nitrites). In May 2025, we added verbiage to the Epic orderable emphasizing the criteria. Methods: Using the EMR, lists of urinalyses were generated before the reflex criteria change (August 2023, n=229), after (March 2024, n=102), and an additional data pull June/July 2025 to identify patients who had urinalyses done, and to further identify those who had rejected cultures based on the reflex criteria. A subset for pre/post were reviewed, and all patients with rejected cultures were reviewed. Their charts were reviewed and relevant data captured in RedCap databases. Results: Comparing pre-change (n=229) and after (n=102), there was no difference in the two groups for bacteriuria, leukocyte esterase, WBC, nitrites, and epithelial squamous cells (p=0.31). Antimicrobial prescribing was similar between the groups (p=0.17). Out of 24,978 urinalyses with microscopy in June/July 2025, 291 patients had urinalyses that were rejected for cultures (0.012%). Of the 291 patients, 5 were male, 3 nonbinary, and the rest female. Fifty-eight were pregnant persons. Mean body mass index was 32 mg/m2. The top five most common chief complaints were gastrointestinal (n=86), genitourinary (n=46), obstetric (n=41), gynecologic (n=17), musculoskeletal (n=17). For clinician reasoning from note review, most were ordered for suspected urinary tract infection or urinary symptoms (n=134), no rationale documented (n=52), obstetric workup (n=51), metabolic workup (n=16) or sepsis workup (n=16). Ten patients returned to the ED subsequently, but none required additional workup related to their rejected culture. Conclusions: There were no differences between the characteristics of patients between the reflex culture changes. Very few cultures ultimately were rejected due to skin contamination, emphasizing that rejecting samples for culture is a viable option to improve diagnostic stewardship. The predominance of female and obese patients with contaminated urinalyses emphasizes additional attention to urine collection techniques. Fifty eight obstetric patients were ordered routine urinalyses, not following the orderset obstetric patients excluded from reflex culturing; providers need to be educated to ensure they follow pathways in place. Improved documentation about symptoms and different uses for urinalysis is is key for interpretation of this test.

Background: Antimicrobial resistance (AMR) among urinary pathogens threatens the effective treatment of urinary tract infections (UTIs) worldwide, but regional surveillance data from Western India remains limited. In this study, we aimed to characterize trends of the most prevalent uropathogens from multiple medical centers in Maharashtra and identify patterns within their AMR profiles. Methods: This is a multicentric international collaborative project using de-identified patient samples collected from multiple healthcare sites in Navi Mumbai. 300 urine samples were collected by our collaborative medical laboratory and processed in accordance with the Clinical and Laboratory Standards Institute (CLSI) guidelines. Across gender and age groups, data was analyzed for the distribution of uropathogens and their AMR patterns. Results: A total of 129 (43%) positive urine cultures were identified including 90 samples from women (69.8%) and 39 from men (30.2%). Gram-negative bacteria were isolated from 116 (89.9%) positive cultures, with a predominance of Escherichia coli (46.6%), Klebsiella pneumoniae (37.9%), and Acinetobacter baumannii (11.2%). E. coli was the most prevalent isolate in ages 19-50 (52%) followed by K. pneumoniae (34.7%). In ages 51-90, K. pneumoniae predominated (43.9%) followed by E. coli (36.6%). Prevalence of A. baumannii was modestly higher than reports from neighboring regions in India. 68.5% of E. coli and 50% of K. pneumoniae isolates showed multi-drug resistance (MDR). E. coli showed the highest resistance to penicillins (94.4%), oral cephalosporins (66.7%), and beta-lactam/beta-lactamase inhibitors (53.7%). K. pneumoniae was most resistant to penicillins (100%), beta-lactam/beta-lactamase inhibitors (91.3%), and fluoroquinolones (50%). Resistance to fluoroquinolones (50%) in both species was lower than reported in previous studies from Western India (70–78%). The highest sensitivities for E. coli and K. pneumoniae were observed with carbapenems (100%, 97.7%), nitrofurantoin (94.4%, 88.6%), and amikacin (94.4%, 86.4%). Conclusion: Our study emphasizes the need for ongoing monitoring of predominant uropathogens and their AMR profiles at the regional level. Demographic differences between the prevalence of E. coli vs K. pneumoniae suggests potential host or exposure factors influencing pathogen distribution, warranting further research. The strong activity of nitrofurantoin supports its continued use as first-line empiric therapy.

This article argues that in asymmetric international relationships, gratitude functions as a technology of disciplinary power through which material assistance is converted into moral indebtedness. Unlike material conditionality, which constrains what subordinate actors can do, gratitude constrains what they can say, claim, and be within the relationship, delegitimizing resistance by recoding it as emotional deviance. Integrating Maussian gift theory, emotional-regime analysis, and speech-act approaches to emotion, the article theorizes a specific causal sequence: material assistance is framed as a morally valorized gift, which generates a debt of gratitude, which prescribes an emotional performance of acknowledgment and deference, which in turn constrains the subordinate actor’s capacity to contest donor authority. Empirically, the argument is developed through a comparative emotional-discursive analysis of two structurally asymmetric alliances: the Soviet-Cuban relationship during the 1962 Missile Crisis and the U.S.-Ukraine relationship (2022–2025). Across both cases, great powers mobilized gratitude as a reactive disciplinary instrument, deployed to reassert authority at moments when influence risked erosion. The article contributes to the emotional turn in IR theory by demonstrating that hierarchy is mostly sustained through emotional regimes that prescribe what subordinate actors must feel, display, and acknowledge.

Background: During the 2024 national shortage of BD BACTEC blood culture bottles, many hospitals implemented ordering restrictions to conserve supplies. While prior studies have evaluated overall blood culture utilization and patient outcomes, less is known about how such restrictions affected the observed epidemiology of bloodstream infections (BSIs) across organism groups. Understanding these effects is important for interpreting surveillance data and anticipating downstream clinical implications during diagnostic supply disruptions. Methods: We conducted an interrupted time series analysis of BSI episodes at two tertiary-care hospitals from June 26, 2023 through June 25, 2025. A systemwide electronic order restriction implemented from June 26, 2024 through December 23, 2024 limited clinicians to one blood culture set per patient every 24 hours. We grouped blood culture results into episodes and categorized by organism group. Outcomes included organism group-specific episode incidence, hospital outcomes (e.g., in-hospital mortality/hospice discharge), and blood culture utilization. We used segmented regression models with Newey-West standard errors to estimate level and slope changes associated with restriction onset and withdrawal. Results: We identified 5,391 BSI episodes among 4,484 patients, with baseline characteristics stable across study periods (Table 1). Organism group incidence, hospital outcomes, and blood culture utilization varied by period (Table 2). During the restriction period, the relative incidence of enterococci, fungi, gram negative rods, and Staphylococcus aureus/lugdunensis increased, while anaerobes, streptococci, coagulase-negative staphylococci/common commensals, and polymicrobial infections decreased (Figure 1). Interrupted time series analyses demonstrated an overall decrease in BSI incidence during the restriction, with declines for gram negative rods, streptococci, coagulase-negative staphylococci/common commensals, and polymicrobial infections (Figure 2). We observed statistical significance only for a 51.7% decrease in streptococci incidence upon restriction onset (P=.04) and a 3.5% per month decrease in gram negative rod incidence during restriction (P=.02) (Table 3). Estimates for other organism groups were limited by small numbers of observations, resulting in imprecise effect estimates or potentially artifactual findings. Conclusions Single-set blood culture restriction during the 2024 national supply shortage was associated with changes in the observed epidemiology of BSIs, including an overall decrease in incidence and heterogeneous effects across organism groups. Although interrupted time series analyses for several groups were limited by low power, combined visual and quantitative findings suggest that restrictive diagnostic practices may differentially affect BSI detection by organism type. These findings underscore the need for cautious interpretation of surveillance data during diagnostic disruptions and highlight the importance of resilient diagnostic supply chains and evidence-based mitigation strategies.

Background: Multidrug-resistant organisms (MDROs) are prevalent in skilled nursing facilities (SNFs), but patterns of pathogen movement in these facilities are not well understood. We used genomic surveillance to identify MDRO presence on environmental surfaces, focusing on shared mobile medical equipment (MME) and patient room surfaces, to assess contamination patterns in a skilled nursing facility setting. Methods: We conducted environmental microbiological sampling in an 18-bed floor of a community-based, ventilator-capable SNF over four consecutive days. We collected composite samples of patient room environments and five types of shared MME: glucometers, vital signs carts, shower chairs, shower beds, and patient lifts. The timing and location of each sampling event were recorded. 105 samples were collected, cultured on selective media (for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus species, extended-spectrum ?-lactamase producing Enterobacteriaceae, and multidrug-resistant Acinetobacter species), and presumptive MDRO isolates were MALDI-TOF confirmed and whole genome sequenced. We assessed pairwise genomic relatedness using split-kmer analysis for any MDRO species that was isolated at least twice. We established genomic clusters based on two criteria: the proportion of kmers that matched between isolates (< 0.9) and a single-nucleotide polymorphism (SNP) threshold for each MDRO species based on established literature (e.g., < 7 SNPs). Results: In the 105 samples, four MDROs were detected more than once: vancomycin-resistant Enterococcus faecium (VREfm; N=17), methicillin-resistant Staphylococcus aureus (MRSA; N=9), Klebsiella pneumoniae (KP; N=4), and Acinetobacter baumannii (AB; N=2). To date, MRSA isolates have not been whole genome sequenced and are thus excluded from our results. MDRO detection rates varied across species and sample locations (Table 1). To assess whether these detections indicated pathogen movement, we assessed genomic relatedness (Figure 1) and found: 12 out of 17 VREfm isolates belonged to three multi-isolate clusters of sizes ranging from two to seven isolates; three out of four KP isolates formed a single cluster; while the two AB isolates were unrelated. All four clusters that were detected in the study included isolates collected from shared MME. Three of the four clusters detected involved samples taken in more than one location within the ward, with the largest cluster involving VRE isolates collected from five unique patient rooms and three equipment types stored in a hallway (Figure 1). Conclusions: Our findings suggest that MME may be an important reservoir for MDROs and can facilitate pathogen movement between patient rooms in SNFs. Adequate cleaning of shared MME is necessary to address the risk of fomite-based

Lichens are multispecies consortia that visually and semantically masquerade as an ‘organism’, but beneath this illusion lies a fundamental challenge: how do we identify an ‘individual’ for our research? Our aim here is to offer a guide to some of the primary perspectives on individuality as they might apply to lichen symbioses, with an emphasis on the advantages, limitations and best use contexts for each. We introduce three perspectives of individuality that are relevant to the study of lichen symbioses: morphological, physiological and evolutionary individuality. By describing how each framework applies to lichen symbioses, we aim to clarify how individuality is realized in practice, and why these distinctions matter, not just for philosophical debates, but for empirical questions about diversity, biology and evolution. The goal is to emphasize why these different perspectives are relevant to our current research applications in lichenology, and how engagement with these ideas can challenge our current understanding of the symbiosis in constructive ways.

Methicillin-resistant Staphylococcus aureus (MRSA) is associated with high morbidity, mortality, and outbreaks in neonatal intensive care units (NICU). For MRSA-colonized patients in the NICU, the Society for Healthcare Epidemiology in America recommends continuing contact isolation until NICU discharge, reflecting limited evidence to support safe discontinuation and recolonization concerns. We evaluated MRSA colonization dynamics in a NICU with an active surveillance program to better inform the evidence base for contact isolation practices. All patients in the 58-bed NICU at UCSF Benioff Children’s Hospital San Francisco undergo weekly or biweekly MRSA culture screening. Colonized patients are placed in single-patient rooms on contact isolation for the duration of their NICU admission and undergo decolonization with intranasal mupirocin and topical mupirocin or chlorhexidine wipes; parents are also offered decolonization. We conducted a retrospective review of MRSA surveillance data from January 1, 2021 through December 31, 2024. A patient colonization episode was defined as one or more consecutive positive screens, with multiple episodes separated by at least one negative screen. Comparisons between patients with single and multiple colonization episodes were performed using the Mann-Whitney U test. Among 2,352 patients screened, 111 (5%) had at least one positive MRSA screen and of these, 80 (72%) had a single positive screen. The median time to first positivity (TFP) was 20 days (interquartile range [IQR]: 6-59) and the median length of stay (LOS) was 65 days (IQR: 24-134). Ninety-three (84%) patients had a single colonization episode and 18 (16%) had multiple colonization episodes (Figure 1). Compared with patients with one colonization episode, patients with multiple colonizations had similar median TFP (18 vs. 21 days; p=0.25), but a longer median LOS (98 vs. 49 days; p<0.01) (Figure 2). Colonized patients were placed on a cumulative 5,180 contact isolation days (median: 26 days per patient, IQR: 12-63 days); of these, 2,543 contact isolation days (49%) were during weeks with a negative screen. In a NICU with active MRSA surveillance, targeted decolonization, and robust horizontal infection prevention practices (e.g. hand hygiene, personal protective equipment, and environmental cleaning), MRSA colonization and recolonization detection was lower than previously reported in the literature. Despite this, contact isolation days accumulated substantially, with almost half of the days occurring during periods of negative surveillance testing. These findings highlight the need for further studies to assess MRSA recolonization risk and optimize the duration of contact isolation in NICU patients, ideally guided by local epidemiology and active surveillance.

Background: The 2025 American Thoracic Society Community-acquired Pneumonia (CAP) guidelines conditionally recommend that patients hospitalized with non-severe CAP who reach clinical stability be treated with <5 days (3 day minimum) of antibiotics. To determine whether hospitals were implementing or planning to implement this recommendation, we surveyed 68 hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). Methods: Hospitals participating in HMS completed an electronic survey in October and November of 2025. Abstractors were asked to answer (with stewardship team input) whether their hospital recommended (or planned to recommend) 3-day antibiotic treatment for any patients with CAP. If yes, they were asked a) which patient subgroups, b) whether their hospital guideline recommended 3 days, and c) what stewardship interventions they had implemented to increase 3-day durations. All hospitals were asked about barriers. Results: All hospitals (68/68) responded to the survey; 21% (14) reported they currently recommend a 3-day duration for at least some patients with CAP; another 18% (12) do not but are planning to. Hospital characteristics by response category are shown in Figure 1. Of hospitals already recommending or planning to recommend a 3-day duration, 31% (8) recommend it (or plan to) in all patients with CAP. Among the 18 hospitals recommending/planning to recommend a 3-day duration for only a subset of patients, commonly stated criteria were: clinical stability (55%), non-severe CAP (33%), or uncomplicated CAP (33%). Most hospitals (79%) recommending a 3-day duration included the 3-day recommendation in their CAP guideline and 71% reported at least one stewardship intervention in place to increase use of 3-day durations (10, education; 3, audit and feedback; 2, pharmacist bundle; 1, orderset; 1, discharge-specific intervention). Commonly reported barriers or reasons for not recommending a 3-day duration included: focus on 5-day duration (31%), resource/time limitation (14%), EHR transition (12%), and inability to recommend a 3-day duration unless the entire healthcare system did (10%). Notably, 7% expressed confusion about IDSA endorsement of the ATS guidelines (IDSA endorsed the <5 day duration but not the viral pneumonia recommendation). Conclusion: Just over a third (38%) of Michigan hospitals currently recommend or plan to recommend a 3-day antibiotic duration for at least some hospitalized patients with CAP. For the remaining 62% of hospitals, continued focus on 5-day duration, standard barriers around stewardship infrastructure, and concerns about existing evidence, safety, and guidance limit enthusiasm for a 3-day duration.

Background: Candida auris is a globally emerging, multidrug-resistant fungal pathogen that causes serious, difficult-to-treat infections in hospitalized patients. C. auris cases in the United States have been linked to receipt of healthcare overseas. Outbreaks have also occurred in New York City, New Jersey, Illinois, Nevada, and California. We provide care to patients from all 50 states and 138 countries and are therefore, at risk for encountering C.auris within our facility. Methods: A case-finding tool was created by Infection Prevention and Control (IPAC) within the electronic medical record (EMR) to identify patients for screening. Inclusion criteria was centric to patients who were admitted in the previous 24 hours with a primary address in a foreign country or in areas of the United States with known C. auris transmission. Patients who are positive for Carbapenamase-producing organisms (CPO) are also included in screening criteria. In 2020, Clinical Microbiology validated a polymerase chain reaction (PCR) test in partnership with the State Health Department and IPAC. In January 2022, IPAC created a protocol that allows IPAC staff to order C. auris screening directly in the EMR utilizing the validated PCR test. The order is paired with communication from IPAC alerting the patient care team that C.auris screening is indicated. Instructions on test collection and information on C. auris are also included in messaging. The patient’s primary nurse then obtains verbal consent from the patient to collect a composite axilla–groin skin swab. Swabs are sent to Clinical Microbiology for testing, and results are reported directly into the EMR. Results: Since the introduction of the nursing protocol in January 2022, 2,660 patients have been identified for C. auris screening through November 2025. Of the 2,660 patients identified for testing, 1,111 patients had screening completed. Two patients tested positive for C. auris on screening. Both patients had prolonged travel to regions with known C. auris transmission. Conclusion: The EMR can be leveraged for early identification and screening of patients at risk of C.auris colonization. Case finding tools, combined with nursing protocols and communication strategies within the EMR can be effectively replicated and modified to respond to emerging infections.

Background: Ventilator-associated events (VAEs) are episodes of respiratory deterioration after stability during mechanical ventilation, posing significant risks for morbidity and mortality. Extremely low birth weight neonates (<750 g), particularly those born at 22–24 weeks gestation, are highly vulnerable. In our Neonatal Intensive Care Unit (NICU), eight VAEs occurred in the previous year, leading to prolonged ventilation, increased infection risk, and higher mortality. Reducing VAEs is essential for improving patient safety, health equity, and family experience while meeting NHSN benchmarks and regulatory goals. Methods: A structured, evidence-based approach was implemented using failure mode effects analysis (FMEA) to identify risk factors and guide interventions. A multidisciplinary team developed a formalized VAE prevention bundle, which included: - Formation of a multidisciplinary task force - Process measures tied to critical clinical tasks - Creation of an EHR tool for real-time compliance monitoring - Staff education and workflow alignment - Cultural engagement initiatives to reinforce best practices Pre- and post-intervention data were collected and analyzed for neonates <750 g per NHSN guidelines. Result: Post-implementation, VAE rates decreased from 9.8 to zero per 1,000 ventilator days, achieving an SIR ?1.0 and meeting national benchmarks. Mortality among extremely low birth weight neonates declined by 60%. Integration of EHR visualization and Power BI dashboards enabled real-time monitoring and sustained compliance. The initiative generated an estimated annual cost savings of $2.1 million through reduced length of stay and infection-related expenses. Conclusion: Structured care bundles, integrated data tools, and multidisciplinary engagement can eliminate VAEs in high-risk neonates. Broader adoption across NICUs could enhance patient safety, reduce healthcare costs, and improve outcomes systemwide. Innovative clinical practice plays a pivotal role in sustaining these improvements through adherence to prevention bundles, leveraging technology for real-time compliance, and fostering a culture of accountability. Standardized frameworks and education strategies can be scaled across institutions for continuous improvement. References Bondarev DJ, Ryan RM, Mukherjee D. (2024). The spectrum of pneumonia among intubated neonates in the neonatal intensive care unit. Journal of Perinatology, 44(9), 1235–1243. https://doi.org/10.1038/s41372-024-01973-9 Niedzwiecka T, Patton D, Walsh S, Moore Z, O'Connor T, Nugent L (2019, October). What are the effects of care bundles on the incidence of ventilator-associated pneumonia in pediatric and neonatal intensive care units? A systematic review. Journal for Specialists in Pediatric Nursing: JSPN. https://pubmed.ncbi.nlm.nih.gov/31332968/

This paper reconceptualizes aesthetic action in John Stuart Mill’s art of life as a distinct, world-regarding action, oriented toward ideals such as justice, beauty, and nobility. While morality is guided by obligations to others and prudence by rationality and the cultivation of virtues, aesthetics concerns the aspirational pursuit of collective human flourishing. Rejecting character-based interpretations, the paper distinguishes aesthetic action by its transformative effect and expressive quality. Though not enforceable, aesthetic ideals expand moral imagination and inspire long-term social progress. Drawing on Mill’s separation between action and character evaluation, the argument clarifies that aesthetic action cannot be reduced to virtue or character. Instead, it completes Mill’s tripartite normative framework by illuminating a third domain that motivates ethical life through nobleness and imagination. Aesthetic action thus becomes essential to understanding Mill’s perfectionist aspiration and his vision of higher happiness.

Background: Antimicrobial resistance in Clostridioides difficile threatens frontline therapies, particularly vancomycin and metronidazole. Rapid genomic screening can flag putative resistance mechanisms, informing infection prevention and stewardship. We present pilot WGS data focused on vancomycin- and metronidazole-associated determinants. Methods A multicenter collection included the University Hospital in Kraków and five long-term care facilities in Małopolska, in 2022-2023. Sixty-six C. difficile strains were sequenced (WGS, AVITI PE300) and analyzed bioinformatically (Genpax IDEM, version 2.6); eight originated from colonized individuals, the remainder from CDI cases. We extracted the prevalence of vancomycin-associated genes (vanR-Cd, vanS-Cd, vanT-Cd, vanG, vanZ1, and vanS-Cd_T369I variant) and the metronidazole-associated gene nimB-Cd. Results Markers linked to vancomycin resistance were frequent: vanR-Cd (93.9%), vanT-Cd (71.2%), vanS-Cd (63.6%), vanG (59.1%), vanZ1 (51.5%), and vanS-Cd_T369I (4.5%). The metronidazole resistance marker nimB-Cd occurred in 95.5% of isolates. Notably, only one strain lacked any vancomycin resistance gene, and this isolate was recovered from a patient with CDI. These pilot genomic findings suggest widespread carriage of loci associated with reduced susceptibility to vancomycin and metronidazole in our regional C. difficile population. Conclusions In this pilot dataset, C. difficile isolates frequently carry genomic elements associated with vancomycin and metronidazole resistance. However, the mere presence of these markers, such as nimB or genes under vanRS regulation, may not independently indicate phenotypic resistance without specific functional mutations or regulatory changes. Phenotypic confirmation remains essential to establish clinical relevance; standardized susceptibility testing and integration of genotypic–phenotypic correlations with clinical data will follow in the next phase. Until then, these preliminary WGS results should be interpreted with caution and primarily guide prioritization of surveillance and stewardship actions.

Background: University Health (UH) Medical Center is a longstanding 238-bed safety net hospital in Kansas City, MO, that uses LabID Event Reporting for Clostridioides difficile infection (CDI), with pre-agreed intuitional testing criteria, and where there was an increase in hospital-onset (HO) CDI in 2024. We sought to examine the factors associated with HO CDI at UH. Methods We conducted a case-control study that included all patients (cases) with a positive polymerase chain reaction (PCR) for toxigenic C. difficile in 2024, on hospital day < 3. We defined HO CDI as positive PCR occurring on hospital day < 3. We matched the cases 1:1, by age and gender, with patients (controls) having a negative PCR for toxigenic C. difficile in 2024, on hospital day < 3. Electronic health record was used to extract data that included demographic and epidemiological variables, Charlson Comorbidity Index (CCI), onset of diarrhea, and timing of stool collection, length of stay, and exposures (within past six months of CDI) to hospitalization, surgery, and/or medications including laxatives, proton-pump inhibitors, immunosuppressants, and antimicrobials. Continuous variables were compared via Mann-Whitney U or t test. Categorical variables were compared using X2 or Fisher’s exact test. Univariate and multivariate logistic regression analyses were performed to assess relationship between dependent and independent variables. Statistical significance was at p< 0.05. Results In 2024, there were 20 cases of HO CDI that were matched in 1:1 ratio with 20 controls. The controls had a higher mean CCI than the cases (5.9 vs 3.5). In univariate logistic regression, eight variables had a p-value < 0.05: CCI; cephalosporin use; specialty consults; infectious disease consult; fever; ICU stay; IV contrast receipt; and liver disease. In a multivariate logistic regression model, adjusted for multicollinearity including just five variables, the CCI (OR = 0.38, p = 0.018), specialty consults (OR = 0.00, p = 0.011), and cephalosporins use (OR = 15.06, p = 0.050) were significant; In a final reduced model (removing consults), only the CCI remained significant (p = 0.023). For each one-unit increase in the index, the odds of being a case decreased by 36% (OR = 0.64). Conclusion Charlson Comorbidity Index was a negative predictor, while cephalosporin use was a positive predictor, of HO CDI at UH. Two-step C. difficile testing and tailored antimicrobial stewardship would help optimize diagnosis and management.

Background Blood cultures obtained in the emergency department (ED) are critical for diagnosing bloodstream infections but are frequently compromised by suboptimal sampling practices, contamination, and delays in transport to the microbiology laboratory. These limitations reduce diagnostic yield and may contribute to inappropriate antibiotic use. We evaluated the impact of a sustained, multicomponent quality-improvement intervention on blood culture quality, diagnostic yield, timeliness of transport to the microbiology laboratory, and time to culture growth. Methods We conducted a retrospective analysis of all blood cultures obtained in the ED of an acute-care hospital between January 2019 and December 2025. The ED treats approximately 85,000 patients annually. A multicomponent intervention was initiated in January 2021 and included repeated staff education, quarterly performance feedback, and workflow optimization. Blood culture transport was transitioned from manual delivery to a pneumatic tube system, and diversion tubes were introduced in January 2023 to decrease contamination. Outcomes included annual uptake of two-set sampling, pathogen detection, and contamination rates. Time from collection to incubation and growth was evaluated before and after the intervention. Trends across years were assessed using a test for linear trend. Results A total of 10,729 blood cultures were analyzed. Adoption of two-set blood culture sampling increased over time, from <3.2% (33/901) in 2019 to 45.9% (904/1,971) in 2025 (p<0.001; Figure 1). Overall, the proportion of blood cultures yielding a pathogen increased during the study period, rising from 6.8% (61/901) in 2019 to 12.2% (240/1,971) in 2025 (p for trend <0.001). Pathogen detection was significantly higher when two blood culture sets were obtained compared with a single set (12.9% [455/3,532] vs 8.8% [634/7,197]; p<0.001). In parallel, contamination rates declined markedly, from 13.9% (130/935) in 2019 to 6.0% (173/2,894) in 2025 (Figure 2). Among positive blood cultures, the distribution shifted over time, with contaminants predominating early and true pathogens predominating during the intervention period. (Figure 3) Timeliness of blood culture handling improved concurrently. Median time from collection to laboratory arrival decreased from 9.4 hours (IQR 2.8–14.9) to 2.3 hours (IQR 1.3–4.0; p<0.001). Concurrently, median time from collection to culture growth decreased from 27.7 hours (IQR 20.4–38.5) to 20.0 hours (IQR 14.6–29.3; p<0.001). Conclusions A sustained, multicomponent quality-improvement intervention in the ED was associated with improved blood culture diagnostic yield, reduced contamination, shorter laboratory processing times, and earlier growth detection. These findings highlight the value of coordinated process optimization to advance diagnostic stewardship and patient safety in high-acuity settings.

Background: Advanced planning and adaptable response strategies are essential for preventing measles transmission in healthcare facilities. Objective: To describe a measles management plan and subsequent modifications in response to a cluster of measles cases. Methods: Drawing on previously published work (doi:10.1017/ice.2025.49), the Infection Prevention and Control (IPAC) team initiated a multi-disciplinary team and developed a measles preparedness plan with the following domains: Guidance and education; early detection and testing; isolation and patient movement; contact tracing and exposure management (Table 1). In October 2025, a patient was admitted during their fifth healthcare encounter and was diagnosed with measles. Two family members were later hospitalized with measles. Delayed recognition of the first case prompted enhancements to our preparedness framework (Table 1). Results: The first case resulted in 539 exposed patients. The second resulted in 87 exposures, and the third resulted in no exposure. Despite the extensive exposure, zero secondary measles were reported. Conclusion: Proactive planning enabled rapid response to our first case and controlled secondary transmission. Despite extensive planning, delayed identification of the first case caused significant exposures. As the cluster unfolded, we refined our plan, resulting in zero exposures from the last patient and zero secondary cases, despite over 850 exposures. These efforts may guide other healthcare facilities in improving their measles preparedness and response.

Background: Influenza infection has been temporally associated with acute cardiovascular events, including myocardial infarction (MI). We evaluated whether laboratory-confirmed influenza infection is disproportionately present among ED patients presenting with acute MI compared with patients presenting with other common acute diagnoses. Methods: We conducted a retrospective cohort study using TriNetX data from the 2024–2025 influenza season. Adult ED patients (<18yrs) presenting with acute MI were compared to patients presenting with mutually exclusive acute diagnoses, including gastroenteritis, urinary tract infection or urolithiasis, appendicitis, pancreatitis, cholecystitis, pulmonary embolism, aortic dissection, and myocarditis or pericarditis. Patients with COVID infection 30 days prior the ED visit were excluded. Influenza positivity during the ED encounter was defined as the outcome. All comparisons were adjusted using 1:1 propensity score matching for demographics, cardiovascular risk factors, chronic respiratory disease, and healthcare utilization indicators. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated. Results: Across propensity score–matched comparisons, influenza infection was consistently more prevalent among ED patients presenting with acute MI than among most comparator diagnoses. Influenza positivity was significantly higher in MI compared with gastroenteritis (RR 1.97, 95% CI 1.76–2.20), urinary tract infection or urolithiasis (RR 2.29, 95% CI 2.08–2.52), pancreatitis (RR 3.84, 95% CI 2.90–5.08), cholecystitis or cholelithiasis (RR 3.38, 95% CI 2.92–3.91), and appendicitis (RR 5.58, 95% CI 3.62–8.61). Among high-acuity cardiovascular chest-pain presentations, influenza positivity remained higher in MI compared with pulmonary embolism (RR 1.46, 95% CI 1.27–1.68) and aortic dissection (RR 1.85, 95% CI 1.59–2.15). In contrast, no significant difference was observed between MI and myocarditis or pericarditis (RR 0.79, 95% CI 0.51–1.23). Conclusions: In this diagnosis-based, propensity score–matched ED analysis, laboratory-confirmed influenza infection was disproportionately prevalent among patients presenting with acute myocardial infarction compared with a broad range of other acute ED diagnoses. The persistence of this association across infectious, surgical, and high-acuity cardiovascular comparators, alongside the absence of association with myocarditis or pericarditis, suggests that the observed association is not simply due to patients being sicker or undergoing more intensive diagnostic evaluation. These findings are hypothesis-generating and support further investigation into temporal and mechanistic links between influenza infection and acute coronary events.

Background: Artificial intelligence (AI) chatbots are increasingly used by patients and caregivers seeking quick, conversational answers to medical questions. This trend raises concerns about the clinical accuracy and appropriateness of responses, which can influence illness beliefs, treatment expectations, and care-seeking. These concerns are relevant for conditions like asymptomatic bacteriuria (ASB), which is often mistaken for urinary tract infection (UTI), leading to unnecessary antibiotic use. We examined how AI chatbots respond to simulated caregiver questions about ASB/UTIs. Methods. We created two clinical scenarios of hypothetical medical advice questions involving a positive urinalysis without specific UTI symptoms (i.e., ASB) that asked explicitly whether the parent had a UTI (Table 1). Scenario A described only a positive test, whereas scenario B included a fever and malodorous urine. For each scenario, we varied the parents’ gender (mother vs. father) and age (68 vs. 84 years). The eight questions were entered into three publicly available AI chatbots (ChatGPT v5, Gemini v3, and Copilot v5) on December 15, 2025, using private sessions with no memory enabled. Two team members independently coded responses, with discrepancies resolved by two additional reviewers. Results. Most responses endorsed the suggestion of UTI (22/24, 91.7%; Table 2). Responses frequently acknowledged alternative explanations for symptoms (17/24, 70.9%) and over half mentioned ASB (16/24, 66.7%). Antibiotics were mentioned in 8 responses (33.3%), with 6 of those noting potential harms. Most responses recommended seeking immediate care (19/24, 79.2%). Tone varied: 9 (37.5%) stressed urgency (e.g., “this is not something to wait on—he needs urgent medical evaluation.”), 5 (20.8%) were reassuring (e.g., “I hear your concern”), and 10 (41.7%) neutral. Only 7 responses (29.2%) provided citations. Responses varied between scenarios. For instance, antibiotic harms were given for scenario A but not scenario B. Within scenarios (Table 3), responses varied by chatbot (e.g., mentioning ASB [0/4; Gemini] vs. [2/4; ChatGPT] vs. [2/4; Copilot]), parent’s gender (e.g., antibiotics suggested [1/6; father] vs. [3/6; mother]); and age (e.g., alternative diagnoses suggested [4/6; 68 years] vs. [1/6; 84 years]). Conclusions: In response to simulated caregiver medical advice requests about ASB, AI chatbots often endorsed the suggestion of UTI and inconsistently referenced ASB, with variability by platform and patient attributes. These patterns may reinforce misperceptions of ASB and promote antibiotic misuse in older adults. Monitoring and improvement of chatbot outputs, alongside patient-facing guidance on how to use and interpret responses, are needed to support guideline-aligned care.

This paper proposes a kinematically redundant wall-climbing robot (CR), which employs a kinematically redundant parallel mechanism (PM) as its main body, combined with a serial mechanism, to achieve wall-climbing motion and avoid the dangers associated with manual operation. The improved Grübler-Kutzbach formula is utilized to analyze the degrees of freedom (DOF) of the PM. Subsequently, a kinematic analysis covering position, velocity, singularity, and workspace is conducted to establish the theoretical basis for the robot’s motion planning. To cope with complex working environments, trajectory planning is carried out for the CR, and the complex path planning problem in space is addressed through hierarchical processing, including global path planning, local path planning, and single-step motion planning. After theoretical analysis, kinematic, singularity, workspace analysis, and trajectory planning method of the proposed CR were verified through simulation experiments, confirming the correctness of the kinematic modeling and trajectory solution. Finally, a physical prototype was built to verify the climbing capability of the robot.