Background: Infection is a common and highly morbid postoperative complication in victims of physical trauma. Current literature analyzing the infectious sequelae of physical trauma predominately comes from military data, where blast trauma, rather than blunt or penetrating trauma, is most common. The epidemiology and management of infectious sequelae of civilian trauma are poorly understood, as is perioperative antimicrobial management of trauma laparotomy. Methods: We performed a single-center retrospective chart review using data from University of Chicago’s electronic medical record (Epic) and the National Trauma Registry. Patients 16 years and older admitted for level 1-2 trauma who underwent laparotomy between 5/1/2018-3/18/2023 were included. Using informatics and manual chart review, we analyzed patient demographics, rates of infection, sites of infection, timing of infection from initial trauma event, and causative organisms. We compared patients based on mechanism of injury (blunt versus penetrating) and whether patients underwent damage control laparotomy (DCL)--where the abdomen is left in discontinuity after the initial laparotomy--or single laparotomy (SL). Results: 430 patients met criteria. The median age was 30. Patients were majority Black (80.9%) and male (80.9%). 80.5% of patients had penetrating trauma, of which 90% were gunshot wounds (GSW). 19.8% had blunt trauma, of which 89% were motor-vehicle crashes (MVC). 19 (4.4%) died during initial stabilization, 199 (46.3%) underwent single laparotomy, and 212 (49.3%) underwent DCL (Figure 1). Of patients that survived initial stabilization, 27 (6.6%) developed a bloodstream infection (BSI), of which 21 (77.8%) came from the DCL group (Figures 2, 3). 19% of BSI in the DCL group were caused by yeast. 30.7% of patients developed a culture-positive surgical site infection (SSI) or intra-abdominal infection (IAI), with a rate of 40.6% in the DCL group (Table 2). Yeast were isolated in 40.5% of patients with positive cultures, 86.3% of which were isolated in the DCL group, with an overall incidence of 20.8% in the entire DCL group. Median time from arrival to infection diagnosis was 11 days. Patients generally received empiric Piperacillin-tazobactam while the abdomen was in discontinuity. Conclusions: Infection in civilian trauma laparotomy often arises as SSI or IAI, and is most pronounced in the DCL population. Yeast represents an unexpectedly high proportion of causative organisms. Further research is required to assess whether yeast burden can be mitigated by either incorporating antifungal prophylaxis at time of initial laparotomy, or by shortening empiric post-laparotomy antibiotic courses.

Background: Contact precautions reduce nosocomial spread of Clostridioides difficile (C. difficile). However, they can decrease patient interactions with providers and delay discharges, so it is imperative precautions are discontinued when appropriate. Patients with discordant C. difficile testing (PCR+/Toxin-) require clinical judgment to determine infection versus colonization. Our institution’s C. difficile isolation protocol categorizes duration based on C. difficile treatment and type of patient floor to reflect this. We transitioned to a new electronic medical record (EMR) in June 2024, which included additional decision support for Contact precaution discontinuation. Prior to new EMR implementation, we hypothesized that patients with discordant C. difficile testing were not being appropriately de-escalated from precautions despite meeting institutional criteria. Methods: This was a retrospective chart review of inpatients admitted to our hospital who had discordant C. difficile testing (PCR+/Toxin-) from July 1, 2023 to October 10, 2023. Patients were excluded if there was no indication of PCR+ (critical value) notification to providers or if patients were on Contact precautions with an additional indication to C. difficile. The primary outcome was the proportion of patients with discordant C. difficile testing who had Contact precautions appropriately discontinued based on internal criteria (Figure 1). Results: A total of 90 patients had discordant C. difficile testing during the study period; 10 were excluded. In the study cohort (n=80), 33.8% (27/80) did not have orders placed for Contact precautions at any time despite positive PCR (Figure 2). Of the remaining 53 patients who were placed on Contact precautions, the median start time of Contact precautions after PCR notification was one hour and 20 minutes.

Of patients who were placed on Contact precautions (n=53), 30.2% (16/53) were treated and deemed to have clinical infection, while 69.8% (37/53) were diagnosed with colonization and not treated for C. difficile infection. Overall, 84.9% (45/53) had appropriate de-escalation of Contact precautions; the remaining 8 (15.1%) had inappropriate de-escalation of Contact precautions and were all in the not treated/colonized group. Conclusion: In our single-institution study, we found higher than expected rates of appropriate Contact precaution initiation and discontinuation; however, 15% still had inappropriate precaution durations. Coupled with the surprising number of patients not initiated on precautions at any time after positive PCR, our results highlighted the need to build clear clinical decision support tools with our new EMR and continual surveillance of providers for adherence to isolation protocols post-implementation.

Background: Rapid identification of patients with carbapenem-resistant Enterobacterales (CRE) on admission to an acute care hospital is critical to prompt initiation of infection control measures. Clinical risk prediction tools can assist in identifying high risk patients and allow facilities to perform targeted CRE screening. We aimed to prospectively validate a previously developed CRE risk prediction tool which incorporates data from current and prior hospital encounters and was incorporated into our electronic medical record (EMR). Method: From 6/2024 – 12/2024 we used an automated daily EMR report to calculate a CRE risk score (probability of a CRE clinical culture within 3 days of hospitalization) for all admissions from the previous day at two hospitals in an academic healthcare network in Atlanta, GA. On select days of the week, we approached a convenience sample of approximately 10 patients with the highest risk scores and obtained a peri-rectal swab on consented patients. Swabs were broth enriched and tested on CHROMagarTM ESBL plates. We used MALDI-TOF and/or the Vitek®2 GN74 panel for species identification and antibiotic susceptibility testing. To evaluate testing accuracy, we defined individuals as high-risk if they had a CRE risk prediction score in the top quartile of scores among patients approached. We calculated the sensitivity, specificity, and positive and negative predictive value of this threshold to predict patients with CRE peri-rectal carriage. Results: 9,422 admissions occurred on sampling days; we approached 720 of which 282 (39%) were consented and tested (Figure 1). Ten patients (3.5%) were positive for CRE: 4 Klebsiella pneumoniae, 3 Escherichia coli, 2 Enterobacter cloacae, and 1 Pantoea species. Among tested individuals, patients with CRE had a higher median CRE risk score (0.19% vs 0.04%), more healthcare exposures, a higher Elixhauser score, and more antibiotic days of therapy (Figure 2). Of the 72 (25%) patients at high-risk (CRE risk prediction ≥0.1%) 6 (8.3%) were CRE positive; using this threshold the sensitivity and specificity were 60% and 80%, respectively, and the positive and negative predictive value were 8% and 98%, respectively. Conclusion: Utilizing an EMR-based risk prediction tool can help identify patients at high-risk for CRE colonization. In healthcare facilities with a low CRE-prevalence, identifying a high-risk subset of patients, even with an 8% probability of CRE, could be a clinically meaningful infection prevention measure. Individual healthcare facilities could adjust the testing threshold based on the hospital and population needs.

Background: Blood culture contamination is a large burden on the health system with significant excessive costs and antimicrobial use. In 2024, a national blood culture shortage required intensive conservation strategies regarding blood culture collection. We developed clinical guidance on blood culture utilization and embedded it in electronic health record (EHR). Our goal is to evaluate its impact on blood culture utilization and anti-MRSA agent usage at our institution. Methods: The antimicrobial stewardship team provided educational communication, and blood culture bottle conservation strategy (BCBCS) recommendations that were embedded into the EHR in July 2024 (Figure 1). Patient charts with a laboratory identified blood culture growing a contaminant in December 2023 (prior to BCBCS) and October 2024 (post-BCBCS) were reviewed. Patients were excluded if they had another clinically relevant pathogen in blood cultures, were discharged prior to blood culture result, or died within 48 hours of blood culture result. Information on anti-MRSA agent (vancomycin, linezolid, daptomycin, ceftaroline) days of therapy (DOT), total hospital blood culture volume, blood culture contamination rates, and ID consultation was collected. Results: 54 patients pre-BCBCS and 29 patients post-BCBCS were reviewed. Anti-MRSA DOT in patients reviewed with contaminated cultures was 161 pre-BCBS and 56 post-BCBCS (Table1). Overall blood culture volume and contamination rate were reduced post BCBCS implementation (Table 2). Total hospital anti-MRSA DOT was noted to be less post EHR guidance as well (1529 pre-BCBCS and 1279 post-BCBS). Conclusions: Reduction in both the volume of blood culture collection and overall contamination rate contributed to a reduction of anti-MRSA therapy at our institution. These results highlight the impact that diagnostic stewardship may have on antimicrobial stewardship metrics.

Background: Isolation and cohorting are essential components of an effective infection prevention and control (IPC) program within healthcare settings to prevent spreading infectious diseases. In Bangladesh, no related study has explored knowledge or practices of isolation and cohorting practice. This study aims to investigate the perception and practice of isolation and cohorting among healthcare workers (HCWs) at tertiary care hospitals in Bangladesh. Methods: From September 2020 to January 2021, this hospital-based, multi-center cross-sectional study was conducted in seven tertiary hospitals across Bangladesh. Participants were HCWs (physicians, nurses, cleaning staff) involved in direct patient care and agreed to participate. A pre-tested structured questionnaire was employed through face-to-face interviews for data collection. Descriptive and multivariate analyses were performed using STATA Version 15. Compliance with isolation precautions was categorized into “good” and “poor” groups based on the mean response score. Results: A total of 1511 HCWs were interviewed, in the study. Overall, 88.7% of HCWs were familiar with the terms ‘isolation’ and ‘cohorting’. Still, 40.5% of them did not have a thorough understanding of when to implement these strategies. Only 18.0% of the HCWs reported good compliance towards isolation and cohorting practice. Entry-level (under 31 years) HCWs exhibited better compliance to isolation and cohorting compared to mid-level (31 to 40 years) HCWs (59.6% vs 29.4%). The majority of HCWs (93.7%) who participated in infection control training demonstrated a high level of compliance with isolation. In terms of good compliance with isolation precautions, physicians and nurses had higher odds (OR: 11.0) than cleaning staff. Moreover, HCWs with < 5 years of experience were more likely to comply with good adherence (OR: 1.56, 95%CI: 1.09-2.21) than those with over 10 years of experience. Conclusions: The study revealed that HCWs have a limited understanding and implementation of isolation and cohorting practices. To address this issue, policymakers and hospital leadership should adopt strategies that promote these practices by providing regular training and awareness programs for healthcare workers. Such initiatives are essential to help limit the spread of infections in healthcare settings.

Background: Treprostinil, a prostacyclin analog, is used to manage pulmonary hypertension (PH) through continuous intravenous (IV) infusion via a central venous catheter (CVC) or continuous subcutaneous (SC) infusion via a small infusion pump connected to a catheter. This study compares the incidence and the types of infections between IV and SC administration in a single-center cohort. Methods: We analyzed 49 PAH patients receiving treprostinil at the Hartford Hospital PH Center, all managed under standardized hygiene protocols by the same healthcare team. Of these, 34 received IV administration and 15 SC, based on patient preference and PH specialist recommendations. The primary outcome was the incidence of infection in each group during the study period. The secondary outcome was the type of infection, including bacteremia, cellulitis, or other skin infections, associated with IV or SC administration. Results: The incidence of bacteremia was significantly higher in the IV group, with 7 cases (5 isolated bacteremia and 2 bacteremia with cellulitis), representing 20.6%. In contrast, there were no bacteremia cases in the SC group. Cellulitis was more common in the SC group (20%; 3 out of 15 patients) compared to the IV group (8.8%; 3 out of 34 patients). Notably, 2 cases of cellulitis in the IV group were associated with bacteremia, while all 3 cases in the SC group were isolated, with 1 progressing to an abscess requiring incision and drainage. The overall infection rate (bacteremia and cellulitis combined) was higher in the IV group (29.4%) compared to the SC group (20%). These findings emphasize the higher risk of bacteremia in the IV group and reveal that while cellulitis occurred more frequently in the SC group, the overall infection burden was greater in the IV group. Conclusion: Previous studies show comparable efficacy between IV and SC remodulin when properly dosed. Our findings, despite a small sample size, reveal a higher overall risk of infections, particularly bloodstream infections (BSIs), with IV therapy due to CVC use. This aligns with existing literature identifying catheter-related infections as a key concern. These results support SC remodulin as a safer option, especially for reducing BSI risk. We plan to incorporate these findings into our counseling protocol, acknowledging the need for further validation.

Background: Upper respiratory infections (URIs) are common causes of outpatient visits in children. While many URIs are viral, antimicrobial prescribing remains high. In preparation for action planning to address this issue within our multi-state health system, this study aimed to characterize current antimicrobial prescribing patterns for pediatric URIs in our outpatient setting. Methods: Retrospective analysis of pediatric (<18 years) antimicrobial prescribing for URI diagnosis codes in 639 outpatient sites (nine states), including clinics, urgent cares, and emergency departments (ED) between July 1, 2023 to June 30, 2024. Primary outcome was overall antimicrobial prescribing rates for URIs and by individual URI diagnosis (sinusitis, bronchitis, pharyngitis, otitis media). Logistic regression machine learning model was used with SHapley Additive exPlanations (SHAP) analysis to show feature contributions to antimicrobial prescribing. Results: A total of 125,590 patient visits by children with URI were included. Antimicrobial prescribing rates varied by diagnosis (sinusitis: 53%, bronchitis: 18%, pharyngitis: 45%, otitis media: 40%, p<0.001). Overall prescribing ranged from 18%-52% across states. Patients seen in the ED had the lowest use of antimicrobials (25%) while those seen in urgent care had the highest utilization (58%). Non-bronchitis diagnosis, non-ED encounters, ≤10 years of age, and specific states had the strongest positive associations with antimicrobial prescribing, while race and social vulnerability index (SVI) were not associated. Conclusions: Antimicrobials were most commonly prescribed for pediatric patients seen for sinusitis, pharyngitis, and otitis media. Factors most associated with increased prescribing included non-ED encounters, >10 years of age, and geography. These data support action to standardize practices and address clinical variation.

Respiratory viral infection (RVI) outbreaks pose a significant threat to health. They are associated with patient morbidity and mortality, staff absenteeism, and financial burden on the healthcare system. There is a need for strategies to reduce RVI transmission in hospitals. One proposal is implementation of continuous masking policies. However, the effectiveness of such policies in mitigating RVI spread is unclear. We conducted a systematic review of the literature to determine the effectiveness of continuous masking in reducing the incidence and transmission of RVIs amongst patients and healthcare workers (HCWs) in hospitals. We systematically searched for original articles published between 2000-2024 according to a pre-determined search criterion. Studies were screened by two reviewers in Covidence. One reviewer extracted the data from eligible studies into a pre-determined data extraction form. For studies that reported only count data, results were summarized narratively. Meta-analysis to pool unadjusted or adjusted outcome measures for studies that report a statistical comparison between masking policies and transmission of infections will be considered if appropriate. Joanna Briggs Institute tools will be used for critical appraisal. 3691 studies were identified. 17 met eligibility criteria. 12 studies were conducted in single-center adult hospitals. 4 studies were conducted in pediatric hospitals, with 2 in neonatal centers. One study was conducted on a hospital system. The studied infections were influenza A/B, parainfluenza 1-3, adenovirus, respiratory syncytial virus (RSV), traditional human coronavirus strains, human metapneumovirus, SARS-CoV-2, and rhinovirus/enterovirus. Eight studies assessed the impact of a masking policy on infection rate in patients. All 8 reported masking policies reduce RVI transmission in patients. 9 studies assessed the impact of a masking policy on infection rate in HCWs. 7 were associated with reductions in RVI transmission in HCWs, whereas 2 showed no statistically significant change. The studies identified in this systematic review were associated with a reduction in RVI transmission with the use of continuous masking amongst patients. The evidence for continuous masking was less consistent for preventing RVI transmission amongst HCW with two studies reporting it was not effective. Our findings suggest that masking policies may play a role in RVI prevention but there are significant limitations with the use of observational design and masking in conjunction with other prevention measures. However, assessment of the quality of the papers is pending. Future directions will include assessing secondary outcomes like masking adherence and assessing adjusted analyses form confounding which are critically important.

Background: Overdiagnosis of C. difficile in hospitalized patients is common and contributes to misdiagnosis, unnecessary treatment, and overestimation of nosocomial infection rates. Many institutions, including ours, have implemented computerized clinical decision support (CCDS) with reductions in testing rates, but long-term data on the impact of such interventions are limited. Methods: A previously reported CCDS intervention paired with education campaign and trainee financial incentive was implemented December 2016. A laxative alert was added in 2018 and testing changed from NAAT only to two-step testing in 2020. Hospital-onset C. difficile cases have been reviewed by members of the antimicrobial stewardship team in real time for diagnostic and antimicrobial prescribing opportunities for improvement (OFIs) since 2016, with a stable workflow for unit leadership notification and data entry in RedCap since June 2023. Diagnostic OFI categories are based on themes from early iterations of this case-based review process and include: clinical criteria not met, stool criteria not met, alternative explanation for diarrhea, smells like C. difficile, test of cure, duplicate test, delayed collection, delayed testing, and other. We analyzed reviews from 6/1/2023-12/31/2024 and further classified diagnostic OFI determinations as “No OFI”, “Inappropriate”, or “Appropriate with process OFI”. During the study period there was no ongoing financial incentive or concerted diagnostic stewardship educational campaign, though feedback continued to be provided to individuals and groups based on case reviews, and a single question regarding C. difficile testing was maintained in annual re-training. Results: There were 144 HO-CDI cases reviewed with no diagnostic OFI in 98 (68%). Testing was inappropriate in 16 (11%). Testing was appropriate with process OFIs in 30 (42%). The most common process OFIs were other-stool documentation (11), delayed testing (7), other-lack of discussion with preexisting ID consult (6), and delayed sample collection (5). In cases with delayed testing, earlier testing was not prevented by CCDS in any case. Conclusions: We found relatively low rates of inappropriate testing (11%) over a time period seven years out from initial implementation of CCDS without ongoing active house wide diagnostic stewardship initiatives. Carefully designed and implemented CCDS can be a valuable tool that facilitates sustained improvement and allows resources to be allocated to new efforts. We additionally observed no cases of delayed diagnosis attributable to CCDS with combination of established institutional criteria for testing and two-step testing.

Background: Candida auris (C. auris) and carbapenemase-producing organisms (CPOs) are rapidly emergent healthcare-associated infections (HAIs) with high mortality. Early identification and isolation of colonized patients are crucial in preventing spread. Currently in Oregon, both organism types are uncommonly encountered such that local public health guidance advises travel-related screening as an important component of regional prevention. In 2024, VA Portland Health Care System (VAPORHCS) implemented a C. auris/CPO travel screening program as a quality improvement project. Methods: Using the Plan-Do-Study-Act (PDSA) framework, starting 4/1/2024 patients admitted to acute care were asked, “Have you had an overnight stay in a hospital, nursing home, or other healthcare facility outside of Oregon or Washington in the last year?” If patients responded affirmatively, the admitting nurse educated the patient and collected swabs after verbal consent: axilla/groin swabs for C. auris and peri-rectal swabs for CPOs. Patients were placed on empiric contact precautions in a single-bed room while awaiting results. Infection prevention prospectively monitored the implementation, and retrospectively medical records were reviewed. Results: The PDSA framework informed the implementation and helped organize the approach to addressing barriers such as missed screenings, communication breakdowns, complex disinfection protocols, the need for staff re-education, and delayed C. auris results (see Figure).

Of 3199 acute care admissions between 4/1/24–11/30/24, 72 patients (2.3%) reported a qualifying travel-related risk factor. 64 patients reported overnight healthcare elsewhere in the United States and Territories (including 5 in Puerto Rico) whilst 8 patients had international exposure (Mexico n=6, Philippines n=2). Of the 72 patients with qualifying travel, 9 patients were not tested (patient refused n=2, staff deemed inappropriate n=3, readmission n=1, unknown/technical issues n=3). An additional 32 patients (1%) initially reported qualifying travel but on chart review, travel was not confirmed. Of those, 16 had testing performed, all of which were negative. The average C. auris test turnaround time was 7.7 days with a range from 3-18 days. One patient (2.4%) tested positive for CPO. Conclusion: The C. auris/CPO screening program was effectively implemented and identified one positive CPO case, preventing the need for an urgent outbreak investigation. The PDSA framework helped the organization methodically plan the implementation and address barriers. The long turn-around-time for C. auris testing resulted in undesirable duration of empiric contact precautions. Continued evaluation of program metrics and public health recommendations are critical to sustainment and refinement over time.

Background: We aimed to examine the impact of daily bathing with chlorhexidine gluconate (CHG) on central line associated bloodstream infections (CLABSIs), catheter associated urinary tract infections (CAUTIs), and bloodstream infections with methicillin-resistant Staphylococcus aureus (LabID MRSA) across a large, rural healthcare system. This healthcare system encompasses 8 large community hospitals, one academic hospital, and 11 hospitals with 50 or fewer beds. Starting in August 2023, all facilities were required to adopt daily CHG bathing for patients with central lines and/or in intensive care units. Some facilities also chose to adopt CHG daily bathing for patients with foley catheters. Methods: We analyzed the hospital-wide monthly incidence of select healthcare associated infections (HAIs) in the year before and after implementation of CHG bathing across a large, decentralized, rural healthcare system. We conducted negative binomial regressions to examine the difference in HAIs before/after implementation of CHG bathing, and we used the National Healthcare Safety Network’s (NHSN) predicted numbers of HAIs to adjust for confounding among hospitals. Results: After adjusting for each hospital’s predicted number of infections, we saw a 40.1% decrease in CLABSIs (p=0.008) and a 33.2% reduction in CAUTIs (p=0.018, Table 1); we also observed a 34.3% reduction in LabID MRSA, although this was not statistically significant (p=0.105). Conclusion: System-wide implementation of CHG daily bathing in a large, decentralized, rural healthcare system was associated with a significant reduction in CLABSIs and CAUTIs.

Introduction: Community-acquired pneumonia (CAP) is the leading infectious cause for hospitalization. Guidelines recommend use of a macrolide antibiotic with a beta-lactam for coverage of atypical organisms; however, data supporting macrolide coverage disproportionately include patients with severe CAP. Debate remains regarding the benefit of macrolide coverage among patients hospitalized with non-severe CAP. Methods: We emulated a target trial to evaluate outcomes associated with azithromycin use among patients hospitalized with non-severe CAP between 7/2017 and 8/2024 across 69 hospitals in Michigan. Included patients had an ICD-10 discharge diagnosis code of pneumonia, >2 signs or symptoms of CAP, and radiographic findings. Patients with severe CAP, risk factors for multi-drug-resistant organisms, those not started on standard CAP therapy with a narrow-spectrum beta-lactam with or without azithromycin, or those initially receiving doxycycline were excluded. Time zero was the time of first antibiotic administration on encounter day 1 or 2. Groups receiving and not-receiving azithromycin were balanced using inverse probability of treatment weighting (IPTW) assessed using standardized mean differences (SMD). The primary outcome was time to clinical stability. Secondary outcomes included intensive care unit (ICU) transfer, 30-day rehospitalization, 30-day mortality, and protocol deviation (i.e., azithromycin initiation after time zero [no-azithromycin group], patients receiving <5 days of azithromycin [azithromycin group]). We used the Cox model and multivariable Poisson regression for time-to-event and binary outcomes, respectively. Based on point prevalence of outcomes within our cohort, we were well powered to detect the demonstrated relative differences in all outcomes. Results: Of the 59,698 patients meeting criteria for pneumonia, 19,108 patients were included in the final post-exclusion cohort. Of these, 93.7% (17,904/19,108) received azithromycin on day 1 or 2 (median antibiotic duration 4.0 days [IQR 3,5]), while 6.3% (1,204/19,108) did not. After IPTW, groups receiving and not-receiving azithromycin were well balanced (SMDs <0.1). After adjustment, median time to clinical stability did not differ between the azithromycin and no-azithromycin groups (3 vs 3 days; HR 1.01 [95% confidence interval 0.97–1.14], p=0.74), nor did rate of ICU transfer (0.9% vs 1.3%; HR 0.90 [0.51–1.62], p=0.73). Patients receiving azithromycin had lower rates of 30-day rehospitalization (10.8% vs 15.3%, HR 0.69 [0.58–0.82], p<0.001) and 30-day mortality (2.3% vs. 4.0%; HR 0.70 [0.50–0.93), p=0.03). Protocol deviation occurred more commonly in those initially receiving azithromycin (56.5% vs 11.1%; HR 1.58 [1.32–1.82], p<0.001). Conclusions: Addition of azithromycin to beta-lactam therapy in patients hospitalized with CAP did not influence short-term outcomes but may reduce 30-day rehospitalization and mortality.

Background: Carbapenem-resistant Enterobacterales (CRE) are reportable statewide with required isolate submission to the Minnesota Department of Health (MDH) Public Health Laboratory (PHL), where carbapenemase production and mechanism identification is confirmed. MDH reviews all detected carbapenemase-producing organisms (CPOs) for potential transmission. Suspected transmission clusters are assessed for relatedness using whole genome sequencing (WGS). In 2022, increased detection of multiple bacterial genera of Klebsiella pneumoniae carbapenemase (KPC)-CRE occurred at acute care hospital-A, (ACH-A) and in 2023 the increase in KPC-CRE was accompanied by an increase in New Delhi metallo-β-lactamase (NDM)-CRE detection. Methods: MDH partnered with ACH-A to review increased CPO detection. MDH-PHL conducted WGS including multilocus sequence typing (MLST) and single nucleotide polymorphism (SNP) analysis on isolates. WGS suggested clusters of relatedness spanning multiple years and epidemiologic data revealed common room occupancy. Infection prevention and control (IPC) principles were reinforced in cluster areas and audits verified adherence, prompting consideration of an environmental reservoir. An environmental screening plan was developed focusing on sink drains from common rooms. In May 2024, 94 swabs from sink drains were collected and CPO culture-based screening was conducted using selective media followed by molecular testing of bacterial growth by MDH-PHL. Results: There was detection of CPOs from 28 of 94 (29.8%) sink drains. Eight environmental KPC-CRE isolates and one NDM-CRE isolate appeared genetically related to 22 unique patients over a 10-year period (Figure 1). Three sink drain isolates showed genetic similarity to each other, but not to patient isolates. Three CPO clusters, representing 14 patients, had genetically similar isolates without an associated environmental isolate. However, isolates were collected over months to years suggesting an undetected reservoir. In August 2024, ACH-A initiated mitigation strategies to prevent CPO transmission from environmental reservoirs, including modification of sink plumbing, maintaining a splash zone, refraining from disposal of bodily fluids in sinks, optimizing sink hygiene, and monthly screening of inpatients in units with known CPO sink contamination. From August to December 2024, 325 patients were screened with 1.2% of specimens detecting KPC-CRE colonization. Conclusion: Sink drains containing CPOs on multiple hospital units that correlated with patient cases were identified at ACH-A. WGS suggests intermittent transmission of different CPOs over 10 years, and clusters of transmission appear to be related to environmental sources. Strict implementation and adherence to IPC measures, including those that minimize the spread of CPOs from facility premise plumbing, are critical to prevent CPO transmission despite widespread premise plumbing contamination.

Background: Carbapenem-resistant Enterobacterales (CRE) have become an increasing public health challenge in the United States over the past two decades. Carbapenemase-producing CREs (CP-CREs) significantly contribute to the spread of antimicrobial-resistant pathogens in healthcare settings. Tennessee has been conducting surveillance of CRE since 2011. As part of the Emerging Infections Program (EIP), the state has participated in population-based surveillance in Davidson and seven surrounding counties, collaborating with the Centers for Disease Control and Prevention (CDC) since 2014. Methods: The data collected through the Muti-site Gram-negative Surveillance Initiative (MuGSI) project, a collaboration between Tennessee and CDC as part of EIP, was used for this study. The analysis was performed on a subset of CRE isolates tested for carbapenemase production (CP) among all incident CRE cases collected from 2016 to 2022. Incident CRE cases are defined as the identification of carbapenem-resistant E. coli, Enterobacter cloacae complex, and Klebsiella species (K. aerogenes, K. oxytoca, K. pneumoniae, and K. variicola) from urine or normally sterile specimens (e.g., blood) from the residents of the surveillance area in a 30-day period. The mortality data was obtained from the Tennessee Vital Registry and merged with the surveillance data. Cox regression analysis was performed to evaluate if there is a difference in the 90-day survival rate based on the CP status of the pathogen, gender, age group, and the Charlson comorbidity index (CCI) score. Data analysis was done using SAS version 9.4. Results: There were 570 CRE cases reported during the study period (2016-2022). Of these, 406 were tested for carbapenemase production and 87 (21.4%) were positive for CP. There were 269 (66.3%) females and 137 (33.7%) males. Patients with higher Charlson comorbidity index score (> = 5) have significantly higher hazard ratios compared to those with low scores (HR 4.17; p-value) Conclusion: This study indicates that patients infected with CP-CRE, females, and those with high Charlson comorbidity index score have a significantly higher probability of dying within 90 days. These factors are worth considering when conducting a risk assessment of patients infected with drug-resistant gram-negative bacilli. The significantly increased risk of death among patients infected with CP-CRE highlights the need for timely carbapenemase testing and use of the test result for appropriate antimicrobial therapy and infection prevention.

Background: Urine cultures are the gold standard for urinary tract infection (UTI) diagnosis and are becoming increasingly important to guide antibiotic choice. However, when samples are not collected properly they can become contaminated. In our primary care safety-net clinics, 694 (55%) of all urine samples collected from non-catheterized patients were contaminated, which led to one in five patients receiving unnecessary antibiotics and a waste of lab resources. We have developed a bilingual (English and Spanish), multicultural educational intervention that includes an animated instructional video and a flyer with pictorial instructions providing step-by-step guidance for collecting a midstream clean catch (MSCC) sample. Methods: A patient advisory board (PAB) was assembled to review our materials, recruiting patient representatives from 2 private and 2 public primary care clinics in Harris County. The PAB included 7 Hispanic patients (2 female), 3 Black patients (2 female), and 2 White patients (1 female), of which half were bilingual (50%). Each board member received a urine sample collection kit plus our educational flyer. One-on-one interviews were conducted with each PAB member, during which the educational video and flyer were shown. Using thematic analysis, the interview data was condensed into themes. (Figure 1) Results: There was a lack of awareness of how to collect a MSCC among patients. Most found the educational material to be helpful in clarifying the process, and the graphical elements were especially appreciated by those with difficulty reading. Patients reported confusion around appropriate use of the wipes and lack of pictorial directions for handwashing. Physical impediments reported by patients with the MCSS process included difficulty balancing and stopping urine flow for a mid-stream sample, particularly for elderly females with medical comorbidities. Conclusions: Our educational intervention was well received by a sociodemographically diverse group of patient representatives with minimal improvements needed. Future work involves implementation of this educational intervention into primary care workflows and evaluating its effectiveness in reducing urine contamination. Acknowledgments: This work is funded by R01HS029489-02 from the Agency for Healthcare Research and Quality (AHRQ). Dr. Collazo is funded by the Department of Health and Human Services, Health Resources and Services Administration (T32HP10031).

Welfare regime theory remains a central framework in social policy literature, valued for its theoretical insights and policy relevance. However, as this framework is increasingly applied to countries in the Global South, scholars have questioned whether all contexts fit neatly into the established welfare regime types. Recent contributions suggest adopting a hybrid lens, which recognizes that welfare arrangements often vary within the same country, with different populations experiencing distinct forms of social protection. This study contributes to this evolving debate by exploring the development of Iraq’s welfare system and proposing a hybrid classification within the welfare regime framework. We argue that Iraq functions as a hybrid welfare regime, where access to welfare and social protection is unevenly distributed across different segments of society. In doing so, the study extends welfare regime theory by classifying Iraq as a case of hybrid welfare regime and highlights the importance of hybrid welfare models for understanding welfare systems in the Global South.

We discuss a conjecture of Shokurov on the semi-ampleness of the moduli part of a general fibration.

Background: In 2024, The Joint Commission (TJC) introduced Standard IC.07.01.01 to bolster hospitals’ preparedness for high-consequence infectious diseases (HCIDs) such as novel Influenza, Ebola, and SARS-CoV-2. The standard emphasizes the need for an effective framework for managing emerging pathogens. While a definitive list of HCIDs does not exist, TJC defines HCIDs as, “novel or reemerging infectious agents characterized by high transmissibility, limited or no medical countermeasures, high mortality, and a need for rapid identification and stringent infection control.” We outline the process of developing a policy at a National Cancer Institute-designated cancer center to ensure prompt and efficient management of suspected HCID cases. Methods: The policy development process began with a thorough review of existing hospital policies, infection control protocols, and environmental safety guidelines. Stakeholders from multiple departments including Environmental Health and Safety, Facilities Management, Employee Health and Campus police were consulted in the policy development process. A needs assessment was followed to identify gaps and areas requiring improvement. The policy was designed using key resources, including the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the National Emerging Special Pathogens Training and Education Center (NETEC). A framework based on the CDC’s “Identify, Inform, and Isolate” model was employed, with tailored procedures addressing both clinical and operational aspects of preparedness and response. Results: The final policy grouped HCIDs into five categories: (1) Viral Hemorrhagic Fevers (VHF), (2) Novel Respiratory Viruses, (3) Measles, (4) Bioterrorism Agents, and (5) Other Emerging Pathogens. For each category, the policy delineated specific identification criteria, isolation protocols, and management procedures. It also provided guidance on engineering controls, visitor management, patient placement, environmental cleaning, and transportation. Additionally, the policy included external resources on clinical treatments and broader infection control issues. Conclusion: The development of an HCID policy in accordance with TJC Standard IC.07.01.01 provides a robust framework for hospital preparedness in managing high-consequence infectious diseases. By collaborating with Infection Control teams, healthcare institutions can develop protocols that enable swift, effective responses to emerging pathogens, ensuring adaptability during outbreaks. This policy not only facilitates TJC compliance but also enhances hospital readiness for future infectious disease threats. Moreover, it offers a replicable model that can assist other healthcare organizations in strengthening their emergency response capabilities and maintaining survey readiness in an evolving healthcare landscape.

Background: Investigation of transmission of respiratory viruses (RV) in healthcare setting is understudied. To investigate the transmission dynamics of common healthcare-associated RV infections, we performed retrospective whole genome sequencing (WGS) surveillance of rhinovirus, influenza, human metapneumovirus (HMPV), and respiratory syncytial virus (RSV) at one children’s and two adult teaching hospitals in the Pittsburgh area. Methods: From Jan 2, 2018 to Jan 4, 2020, nasal swab specimens positive for rhinovirus, influenza, HMPV or RSV were collected from patients who had been hospitalized for ≥3 days. Specimens with qPCR Ct values ≤30, HMPV specimens were sequenced using tiled PCR amplicons regardless of their qPCR Ct value. Genomes passed WGS QC if ≥90% of the genome had ≥10× average coverage depth. High-quality genomes were assessed for genetic relatedness using ≤3 single nucleotide polymorphisms (SNPs) as a cut-off. Review of patient health records was performed on all genetically related clusters to identify common epidemiological connections. Results: We collected 436 rhinovirus (n = 291), influenza (n = 50), HMPV (n=47) and RSV (n=48) specimens from 360 patients. Of these, 55% (197/360 patients) were from the children’s hospital and 45% were from the two adult hospitals. Patients ranged in age from 14 days to 93 years old, 61% were male, and 74% were white. We sequenced 61.2% (178/291) of rhinovirus, 78% (39/50) of influenza, and 92% (44/48) of RSV specimens that met qPCR criteria. Among these, 63.5% (113/178) of rhinovirus, 87% (34/39) of influenza, and 89% (39/44) of RSV genomes passed WGS QC. Additionally, 79% (37/47) of the HMPV genomes passed WGS QC. We identified 13 genetically related clusters (n=5 rhinovirus; n=2 influenza; n=3 RSV; n=3 HMPV) containing 34 patients and ranging in size from 2-5 patients per cluster. We identified common epidemiological links between 56% (19/34) of clustered patients. Of these, 63% (12/19) of patients had a same-unit stay, 11% (2/19) shared a common provider, and 26% (5/19) had overlapping hospital stays. On average, genetically related clusters spanned a duration of 17 days (range: 0−55 days). Conclusion: WGS offered valuable insights into RV transmission dynamics in hospitals, which until now have not been rigorously studied. While healthcare-associated RV transmission is common, absence of epidemiological links in 44% of genetically-related cases and the distribution of cluster durations, given the incubation period, highlights the complex transmission dynamics.

Background: Adverse perioperative outcomes remain a major public health challenge despite being largely preventable. Surgical site infection (SSI) is a common preventable healthcare-associated infection (HAI) following surgery. The Barnes-Jewish Hospital anesthesiology department developed an innovative telemedicine model, the Anesthesia Control Tower (ACT), to improve intraoperative care delivery and address predisposing factors for adverse outcomes. The ACT is staffed by anesthesiologists and certified nurse anesthetists who use a customized, electronic monitoring system, bolstered with machine-learning forecasting, to provide real-time clinical decision support to anesthesia providers in the operating room (OR). In the ACT randomized control trial, alerts are generated during surgical procedures and ORs are randomized to receive ACT input based on alerts or not. We were interested in determining the effect of the ACT on infectious outcomes. Methods: We used the existing ACT study design, a randomized control trial, to determine the impact of the ACT monitoring system above on SSI, CLABSI and CAUTI. HAI surveillance was performed by IP specialists using CDC NHSN definitions for SSI, CLABSI and CAUTI. We included CABG, colon, abdominal hysterectomy, hip, and knee arthroplasty procedures performed during ACT hours of operation from July 1, 2018 to January 31, 2023 and compared outcomes among patients by randomization to receive ACT. Here, we report on the intention-to-treat analysis based on randomization status. Results: The final cohort included 8,993 procedure dates including 862 CABG procedures, 2,654 colon surgeries, 2,732 abdominal hysterectomies, 2,105 hip arthroplasties, and 833 knee arthroplasties. Baseline characteristics (e.g. age, comorbidities, wound class) were balanced by randomization status. Characteristics captured during the procedure (e.g., temperature, oxygen) were also similar by randomization status. The infectious outcomes revealed that there was no difference in likelihood of SSI (4.0% vs 4.0%), 60-day CLABSI (0.2% vs 0.3%), or 60-day CAUTI (0.0% vs 0.1%) whether the procedure was randomized to receive ACT input or not. Thirty-day mortality (2.0% vs 1.9%) and readmission (16.6% vs 15.9%) did not differ by randomization. Conclusions: In this intention-to-treat analysis of the impact of a novel anesthesiology monitoring system on HAI outcomes, we did not find a difference in the incidence of SSI, CLABSI or CAUTI. Next, we will analyze the study data in a per-protocol fashion. This RCT was conducted in a resource-rich environment with robustly implemented best practice where a second layer of anesthesiology supervision may confer little benefit. The concept of an ACT may still be helpful in resource-limited settings.