Between 1847 and 1876, the textile factory Todos os Santos operated in Bahia. During these almost three decades, it was the largest textile factory in Brazil and came to employ more than four hundred workers. Until recently, many aspects of the factory’s labour force were hidden. There was a hegemonic narrative that all of these workers were free and waged individuals and that their living and working conditions were extremely progressive for the period. Meanwhile, there was a silence about the employment of enslaved people in the institution as well as a lack of in-depth analysis concerning the legally free workers. This article analyses labour at the Todos os Santos factory. On the one hand, it provides evidence on why the myth about the exclusive use of free and waged workers in the factory was formulated and the interests behind this narrative. On the other, through analysis of data from newspapers, philanthropic institutions, and legal and government documents, it reveals the profiles of the supposedly different classes of free and enslaved workers employed at Todos os Santos—men, women, and children of different colours—showing how complex, and often how similar, their living and working conditions were.

Background: Many practitioners relied on SARS-CoV-2 RT-PCR cycle thresholds (Ct) to remove COVID-specific isolation given data correlating Ct values with the ability to culture live virus. Standardly, Ct values of 28-32 were used to remove isolation. However, many labs stopped reporting these values given lack of clinical validation based on a joint IDSA/AMP statement. VA Boston Healthcare System (VABHS) developed and implemented a clinical algorithm to replace Ct values to determine a need for isolation. We aimed to compare our algorithm performance to the unreported Ct results. Methods: We conducted a retrospective cohort study of COVID-19 PCR positive patients at VABHS between 10/1/23 and 3/31/24. During this time, VABHS required COVID-19 PCR testing (either via Cepheid Xpert Xpress CoV-2 plus or Cepheid Xpress Sars-CoV-2/flu/RSV plus) for admission regardless of symptoms. Included were all patients for whom Infectious Diseases (ID) was contacted to take off isolation using our algorithm (Fig 1). Ct values were later obtained from the lab as part of IRB-approved research to determine sensitivity of the algorithm to correctly classify isolation requirements. Ct values of 28 and 30 were used as the gold standard test for determining need for isolation. Results: ID was contacted to determine isolation requirements for 56 patients for whom the algorithm was applied and Ct values were later available for review. Using a Ct threshold of 28, 44 patients (78.6%) were admitted with appropriate isolation classification via the algorithm; 34 patients off isolation and 10 requiring isolation. Incorrect algorithm classification occurred for 10 patients who were isolated when not required due to lack of additional data; 2 patients who required isolation were not isolated. The algorithm failed in these 2 patients at the use of antibody results for determining time from infection; mean Ct value was 25.6 (range 23.6- 27.6). Both patients had COVID within the last 30 days and positive antibody testing. The true positive rate/sensitivity for algorithm driven isolation was 83.3% (51.6-97.9%) and the true negative rate/specificity for algorithm driven removal of isolation was 77.3% (62.1-88.5%). When the Ct threshold is modified to 30, the sensitivity and specificity of the algorithm were 78.6% (49.2-95.3%) and 78.6% (63.2-89.7%) (table 1). No transmissions occurred using the algorithm during this study period. Conclusions: Strategic use of an algorithm using history, antigen and antibody results was moderately accurate compared to Ct values for assessing isolation requirements. No known transmissions occurred with use of the algorithm in lieu of Ct values.

We develop the theory of limits and colimits in $\infty$-categories within the synthetic framework of simplicial homotopy type theory established by Riehl and Shulman. We also show that in this setting, the limit of a family of spaces can be computed as a dependent product.

Background: Calls within the clinical community for revising guidance on the appropriate durations of antibiotic therapy (i.e., shorter is better) and adherence (i.e., no longer advising to always finish a course), reflect important gains in evidence-based prescribing. However, changing medical guidance can have negative public effects (e.g., frustration, distrust, and disengagement) when not communicated in ways that resonate with patients. To inform efforts to effectively communicate evolving evidence on appropriate antibiotic use, we examined US adults’ perceptions and preferences regarding antibiotic durations and adherence. Methods: From March to April 2024, we invited US adults, aged ≥18 years, to an online survey about antibiotics. Question topics included durations of antibiotic therapy, adherence to a prescribed course of antibiotics, and demographic characteristics. Results: Table 1 shows the characteristics of the 1,476 respondents [completion=89%]. Most respondents reported they preferred to take a longer course of antibiotics (≥7 days) than a shorter one (3-5 days) for a bacterial respiratory infection (60.4% vs. 39.5%) and rated longer courses as both safer and more effective (Table 2). In open-text questions, respondents who preferred shorter courses described a general aversion to medication and concerns about side effects and resistance, whereas those who preferred longer courses saw them as familiar and a ‘better safe than sorry’ approach, associating longer durations with greater efficacy. In addition, 88.4% of respondents agreed that ‘it is important to always finish a prescribed course of antibiotics, even if you start to feel better’ and had either been told this by a medical professional (76.3%) or seen this guidance in a public health message (61.2%). Conversely, only 17.5% said they had ever been told they could stop taking antibiotics early. Preference for longer antibiotic courses was associated with older age, trusting their doctor’s advice about antibiotic therapy durations, having been told by their doctor to ‘always finish a course of antibiotics’, less worry about antibiotic side effects, discomfort about potentially being asked by a clinician to stop taking antibiotics when they start to feel better, and perceiving the clinician suggesting that as less competent. Conclusions: Many US adults prefer longer durations of antibiotic therapy for respiratory infections than are likely necessary. Almost all survey respondents believed it important to always finish a course and many were uncomfortable with advice to the contrary. These findings highlight the need for evidence-based communication strategies for aligning US adults’ antibiotic duration and adherence preferences with current guidance.

Background: Invasive fungal diseases (IFDs) are severe infections caused by fungi that can spread throughout the body, particularly in individuals with weakened immune systems. These infections are increasingly challenging, especially those that are resistant to antifungal treatments. IFDs represent an emerging global threat, highlighting the urgent need for increased attention and research. In 2022, the World Health Organization (WHO) released the WHO Fungal Priority Pathogen List (WHO-FPPL), ranking 19 fungal pathogens as critical, high, or medium based on criteria such as incidence, treatment options, and mortality rates. While Candida albicans and Candida auris are well-known and included on the list, it also features four other species of concern (C. glabrata, C. tropicalis, C. parapsilosis, C. krusei) that are not typically listed on disinfectant master labels. This study aims to evaluate the antimicrobial susceptibility differences between Candida species from commonly used healthcare disinfectant products. Method: Antimicrobial efficacy testing was conducted using common healthcare disinfectants against the WHO-FPPL listed Candida species, following standard operating procedures typically required for disinfectant product registration by the U.S. EPA. Each disinfectant formulation represented a common active ingredient, or active ingredient blend, used in healthcare settings for surface disinfection, ranging from ready-to-use sprays to wipes. Products were tested at approximately 75% of the manufacturer-defined contact time listed on the EPA master label to stress the chemistry and elucidate antimicrobial susceptibility differences between Candida species. Results: Antimicrobial efficacy varied across Candida species for the tested chemistries. Of the six Candida species tested, C. parapsilosis was the most difficult to eradicate. The remaining Candida species exhibited less variability with C.auris and C. krusei demonstrating slightly lower susceptibility across all of the disinfectant types than C.albicans, C. glabrata, and C. tropicalis. Conclusion: This study underscores the variability in efficacy between these emerging fungal pathogens and common healthcare disinfectants. While C. auris remains a primary concern in healthcare settings, these findings highlight the continued need for ongoing fungal surveillance, research of emerging fungi, and the potential impact on environmental hygiene practices.

Background: Empiric antibiotic therapy choices and de-escalation practices for the management of febrile neutropenia (FN) can vary. Facility-specific antimicrobial guidelines have an important role in influencing prescription practices for FN and is a foundation of antimicrobial stewardship activities. Methods: This pre-post quality improvement study at the University of Maryland Medical Center (UMMC) Greenebaum Comprehensive Cancer Center evaluated the impact of the implementation of updated institutional FN guidelines. The changes primarily included: 1) removal of meropenem as first-line agent for patients receiving levofloxacin prophylaxis without other risk factors (e.g. history of resistant organism) and 2) de-escalation protocol for low-risk patients (e.g. afebrile, hemodynamically stable). Education of oncology attendings, residents and pharmacists were carried out. We included patients receiving antipseudomonal antibiotics for FN or sepsis as indicated by prescriber (~70% concordance with antimicrobial stewardship review). Sepsis was included because of high rates of observed misclassification for patients with FN. Stem cell transplant patients were excluded. Pre-intervention (04/2021 – 12/2022) and post-intervention (01/2023 – 09/2024) groups were compared for total anti-pseudomonal antibiotic and meropenem-specific days of therapy (DOT) per 1000 days present (DP) and count of unique antibiotic order per 1000 DP. In addition, a sample of antibiotics reviewed by the UMMC antimicrobial stewardship team was assessed for guideline compliance. Means were calculated across quarters for each period and Willcoxon rank sum was used for comparisons (p Results: A total of 3,311 antibiotics were ordered for FN (79%) or sepsis (21%) during the study period. Longitudinal trends and antibiotic type distribution are illustrated in Figures 1 and 2, respectively. DOT per 1000 DP for all antipseudomonal antibiotics was 213 in the pre-intervention group compared to 191 in the post-intervention group (p=0.06). Meropenem DOT per 1000 DP decreased from 105 in the pre-intervention group to 87 in the post-intervention group (p=0.004). Unique antibiotic order per 1000 DP of all antipseudomonal antibiotics remained constant (62 vs. 56, p=0.1), while unique antibiotic order per 1000 DP for meropenem decreased (16 vs. 8, p =0.01). Of the 317 antibiotics reviewed, 130/169 (77%) were guideline compliant in the pre-intervention group and 113/148 (76%) in the post-intervention group. Conclusion: Changes in FN guidelines at the UMMC cancer center led to decreased meropenem use with a nonsignificant decline in all antipseudomonal antibiotics. Additional work is needed to identify barriers to guideline adherence.

Background: Social vulnerability factors have been associated with negative health outcomes. However, it remains unclear how they affect device-related infections in different population groups. Methods: This retrospective observational cohort study included Central-Line Associated Bloodstream Infections (CLABSI) and Catheter Associated Urinary Tract Infections (CAUTI) in an 850-bed, academic tertiary care facility. Information was collected on patient demographics, the CDC Social Vulnerability Index (SVI), hospitalization, comorbidities, and COVID-19 status. SVI analysis included overall vulnerability comprised of the four themes: socioeconomic status, household characteristics, racial/ethnicity minority status, and housing type/transportation. Chi-square and Wilcoxon rank-sum tests were used for categorical and continuous variable comparisons. GEE models compared pre- and pandemic periods by interrupted time series analysis. Results: Between 1/1/2018 to 5/31/2022 98,791 patients were admitted 151,550 times. Of those, 17,796 patients received 29,483 central lines and 45,180 patients had 65,422 Foleys. 314 patients developed 338 CLABSI and 216 patients had 217 CAUTI. 1,552 patients tested positive for COVID-19 with 22 developing CLABSI and 14 CAUTI. The pre-pandemic downward trend in CLABSI and CAUTI was reversed during COVID-19 (p Throughout the study Black patients had higher device days (p In the SVI analysis the socioeconomic theme was associated with higher risk of device-related CLABSI across the entire study (p=0.03). During COVID-19 overall SVI and the household characteristics theme were associated with higher device-related CLABSI rates (p=0.03; p=0.03). Adjusting for race or ethnicity dissolved those associations. For CAUTI race/ethnicity minority status was linked to an event throughout the study (p=0.03). This held true after adjusting for individual race or ethnicity status. No associations were detected in the pre- and pandemic periods for CAUTI. Conclusions: Health outcome disparities affected Black (CLABSI and CAUTI) and Hispanic/Latino (CLABSI) patients. Of note, both groups had significantly higher device utilization rates. Per-patient infections increased during the pandemic without altering race/ethnicity differences. Higher race/ethnicity minority status SVI was linked to CAUTI. However, CLABSI were driven by the socioeconomic SVI. The findings can help clarify the relationships between race/ethnicity and other demographic and socioeconomic factors associated with device-related infections on the community and individual level.

Background: Multidrug-resistant organisms (MDRO), including those producing extended-spectrum beta lactamases (ESBL) are increasing. Infections, especially with MDRO, lead to increased healthcare costs. Bloodstream infections (BSI) caused by ESBL-producing Klebsiella pneumoniae increased at our institution in 2021-2022. An assessment as to whether these organisms were acquired during hospitalization or other healthcare exposures was conducted. Methods: The rates of ESBL-producing Klebsiella BSI per 1000 hospitalizations in 2021 and 2022 in transplant recipients and non-transplant patients were compared. From 1/1/2021 to 06/30/2023, 49 adult patients at an academic medical center had Klebsiella pneumoniae BSI with ceftriaxone resistance and a high probability of carrying an ESBL. Of these, 20 were transplant recipients and 29 were non-transplant patients. We performed whole-genome sequencing on the 28 available unique patient isolates (12 transplant; 16 non-transplant) to assess relatedness. Additional data were collected by chart review on transplant recipients. BugSeq bioinformatics pipeline and refMLST were utilized on the sequenced isolates to assess clonality, defined as ≤20 allele difference between two isolates. Results: The rate of ESBL-producing Klebsiella BSI increased universally from 2021 to 2022 but impacted the transplant cohort (0.3 to 3.6 per 1000 hospitalizations) more than the non-transplant cohort (0.2 to 0.5 per 1000 hospitalizations). Kidney and liver transplants were most often involved (5 out of 49 patients each). In the transplant cohort, bacteremia alone (45%, 9 out of 20) and urinary source (35%, 7 out of 20) were the most frequently identified etiologies. The most common sequence type was ST-307, accounting for 64% of total sequenced isolates (67% of transplant; 63% of non-transplant). The most common ESBL gene identified was blaCTX-M-15, identified in 24 isolates (86%). Less common resistance genes included blaSHV-12 (N=3) and blaCTX-M-3 (N=1). While there were 5 isolates within 20 allele differences (3 transplant; 2 non-transplant), they were separated in time and did not have obvious epidemiologic connections. While there was a change in TMP-SMX prophylaxis protocol during this time in kidney transplant recipients, it did not explain the increase observed in other transplant groups. Conclusions: There was a sharp increase in the number of BSI caused by ESBL-producing Klebsiella pneumoniae in the transplant population between 2021 and 2022. A molecular epidemiologic analysis ruled out clonal transmission from breakdown of infection prevention practices as the cause. No other common epidemiologic link was identified. This demonstrates the application of whole-genome sequencing in excluding a clonal outbreak from a common source within an institution.

Background: Inappropriate urine culture can lead to unnecessary antibiotic use, antimicrobial resistance, increased healthcare costs, and resource strain. Ensuring the appropriate use of urine cultures aligns with principles of diagnostic stewardship. Methods: Urine cultures ordered from ED in our hospital, for patients who were admitted during July and August 2024 were retrieved from the electronic medical records. Symptoms score based on IDSA guideline (Figure 1) and BLADDER score (Figure 2) were correlated with urine analysis (URE) and cultures for appropriateness. Results: Among 267 urine culture orders that were reviewed, 61 patients were excluded due to indwelling catheter, high-risk neutropenia, recent urological procedures, pregnancy, or recent renal transplantation. The median age of study population (n=206) was 64 years. 50.50% were women. 97 (47.3%) had significant pyuria, and 105 (50.97%) had a positive leukocyte esterase (LE), nitrite positivity was low 13 (6.3%). LE had better correlation with pyuria and culture positivity when compared to urine nitrites. Only 46 patients (22.3%) had culture positivity. Imaging evidence supportive of urinary tract infection was noted in 18 patients. Among 206, only 102 cultures (50.48%) were appropriate as per IDSA guidelines. Inappropriate cultures were ordered for fever (59.6%) without localisation, abdominal discomfort (8.6%), urinary frequency (2.8%), haematuria (1.9%), incontinence (0.9%). 10% were sent as part of order sets, who were asymptomatic and had no significant pyuria or cultures positivity. Among 87 patients with a BLADDER score ≥2, 95.4% of cultures were appropriate, 64.3% had significant pyuria, 36.8% had culture positivity. Among 119 patients with a score < 2, 15.9% of cultures were appropriate, 34.5% had significant pyuria, 11.8% had culture positivity. Positive predictive value (PPV) of BLADDER score for UTI was 77.0%, 89.3% along with pyuria and 88.23 % when combined with pyuria and positive LE. Negative predictive value (NPV) of BLADDER score for UTI was 88.2%, 100% along with absence of pyuria and 100% when combined with absence of pyuria and negative LE (Table 1). Based on our study the proposed algorithm for ordering urine culture, after excluding the high risk group is depicted in the Figure 3. Conclusion: Our study showed 50% of urine culture as inappropriate. BLADDER score can be a useful bedside screening tool for deciding urine culture, PPV and NPV increase when combined with presence or absence of pyuria and LE. Implementing a diagnostic stewardship protocol in urine culture has the potential to improve culture appropriateness, reduce unnecessary antibiotic use.

Background: Patients with suspected pulmonary TB tuberculosis (PTB) often require scarce airborne isolation rooms; minimizing use depends on clinician understanding of sputum and bronchoscopic test characteristics. Limited knowledge can lead to over-testing and unnecessary isolation days, straining hospital resources. Objective: Evaluate the impact of a PTB screening algorithm on reducing unnecessary testing and excess isolation days in patients with low to moderate pre-test probability. Methods: The study occurred 2022–2024 at a 1,286-bed tertiary care hospital in Toronto, Ontario (~880 TB cases annually). Inclusion criteria included inpatients placed on airborne isolation for suspected PTB with orders for either ≥3 expectorated sputa, ≥1 induced sputum, bronchoscopy, or combinations thereof. Patients with suspected Mycobacterium avium complex were excluded. A positive case is TB PCR or culture positive. Harm is defined as PTB exposure due to premature discontinuation of isolation. The algorithm recommended clinicians to collect a single induced sputum for low/moderate-risk patients with additional testing reserved for high-risk cases. Results: A total of 1,152 samples were collected from 747 patients; 513 expectorated sputa (44%), 194 induced sputa (16.8%), 445 bronchoscopies (38.6%). The median isolation duration was 6 days and the turnaround time for results ranged from 3–11 days. The positivity rate was 0.2% for performing expectorated sputum first (1/513), 2.5% for performing induced sputum (3/118) first, and 1.8% for BAL performed first (3/169). When comparing repeated induced sputum testing, all the samples were positive from the first specimen (Figure 2). Conclusion: These findings illustrate the real-world implications of using a single induced sputum to rule out PTB in low/moderate pre-testing probability patients, potentially leading to the reduction in airborne isolation days. No added harm via patient exposures was detected with the use of this algorithm.

Background: The Republic of Korea ranks second among OECD countries for tuberculosis (TB) incidence. National TB control guidelines mandate latent TB infection (LTBI) screening and treatment for healthcare workers (HCWs), especially those in high-risk departments. At our 2,700-bed tertiary hospital in Seoul, annual LTBI screening and treatment have been actively implemented since 2017, targeting HCWs at elevated risk of TB exposure. This study evaluates LTBI conversion rates among high-risk HCWs and characteristics of HCWs with conversion (converters) over the past five years. Methods: Following national guidelines, HCWs were classified into three high-risk groups: those likely to have routine contact with pulmonary TB patients (Group A), those caring for immunocompromised patients (Group B), and those at risk of respiratory infections despite no routine TB contact (Group C). Annual screening included interferon-gamma release assay (IGRA) and chest radiography. HCWs with positive IGRA results (≥0.35 IU/m) were strongly encouraged to undergo latent tuberculosis treatment. We analyzed data from HCWs working in high-risk tuberculosis units who had worked for more than five years from 2020 to 2024. HCWs with prior IGRA positivity were excluded. Results: Among, 1467 HCWs, 15.9% (233/1,467) had been diagnosed with LTBI before 2020, while the cumulative LTBI conversion rate between 2020 and 2024 was 5.3% (65/1,234). The annual LTBI conversion rates ranged between 0.7% and 1.5%. The median age of converters was 42 years, significantly older than non-converters (median 38 years; P = 0.02). Male converters comprised 24.6% (16/65) compared to 14.6% (171/1,169) in the non-converter group (P = 0.03). Longer tenure was observed among converters (median 16 years) than non-converters (median 12 years; P = 0.01). Although medical technicians and emergency room staff exhibited higher conversion rates, these differences were not statistically significant. Among LTBI cases, 78.8% completed treatment, with 9.1% demonstrating reversion. The annual incidence of active tuberculosis among HCWs at our hospital significantly declined to an average of 0.2 cases per year between 2020 and 2024, compared to 4.4 cases per year between 2015 and 2019 Conclusions: Annual LTBI screenings revealed conversion rates of approximately 1%, primarily affecting older, long-tenured, and male HCWs. Active LTBI treatment effectively reduced the risk of active TB among hospital staff.

Background: Candida auris and methicillin-resistant Staphylococcus aureus (MRSA) are prevalent in nursing homes, and both are known to shed profusely from the skin. We evaluated the degree of differential shedding during caregiving activities versus at rest in nursing home residents. Methods: Residents at two nursing homes were screened for C. auris and MRSA using nares, axilla/groin, and peri-rectal swabs. Carriers of C. auris, some of whom also carried MRSA, were evaluated for proximal shed around their bed during rest and caregiving activities using chromogenic settle plates. Morning caregiving activities (e.g. hygiene care, linen/clothing change) were noted to generally take 12 minutes. For rest, settle plates were placed for a 12-minute period prior to the resident awakening in the morning. For caregiving, settle plates were placed for the 12-minute period of morning activity shortly after awakening. Twin rest-caregiving measurements were taken on three separate days per C. auris carrier. In addition, prior to caregiving, bilateral nares, hands, axilla, groin, and perirectal swabs were taken for C. auris and MRSA culture, along with an axilla/groin swab for measuring chlorhexidine concentration (CHG used for routine bathing). Logistic regression with person-level clustering analyzed associations between positive settle plates (“shedding”) and activity (caregiving versus rest), along with other adjusters. Results: The study included 23 C. auris carriers, 15 of whom carried MRSA. 65% were male, 91% had an indwelling device, 39% had wounds. Mean number of positive body sites was 2.3 for C. auris and 1.2 for MRSA. Median CHG concentration was 156 µg/mL (IQR=39-1250). Shedding occurred more frequently during caregiving versus rest for both C. auris (8/69 vs 1/69, P=0.02) and MRSA (15/69 vs 3/69, p=0.002). In multivariable models (Table), caregiving was associated with increased odds of shedding for both C. auris (OR: 9.25 (95% CI: 1.07-80.35), P=0.04) and MRSA (OR: 6.52 (95% CI: 1.72-24.78), P =0.01). Higher CHG concentrations were non-significantly associated with reduced shedding of both pathogens. Conclusion: C. auris and MRSA shedding increased significantly during caregiving activities, supporting CDC’s current recommendations for enhanced barrier precautions in nursing homes, which involve gown and glove use during high-contact care for carriers of multidrug-resistant organisms. Remarkably, shedding was readily detected within 12 minutes of morning caregiving, highlighting a rapid “plume effect” during resident care.

Background: Multidrug resistance remains one of the top global health threats and has been rising over recent decades, jeopardizing patient outcomes and increasing healthcare costs. This underscores an urgent need to design tools to optimize antibiotic prescribing to target these pathogens. Antibiograms are an essential antimicrobial stewardship tool used to provide guidance for empiric antimicrobial selection and information on local resistance. However, facility-level antibiograms are limited to individual institutions and do not reflect regional variations in resistance. Previous studies have demonstrated the feasibility and importance of generating regional antibiograms to better inform regional infection prevention and spearhead antimicrobial stewardship initiatives. Regional antibiograms also offer a valuable resource for community hospitals and health centers with lower pathogen prevalence and limited access to infectious diseases-trained personnel. This study aims to curate a regional antibiogram to analyze and understand antimicrobial susceptibility and resistance patterns of targeted pathogens across Metro Atlanta. Methods: This descriptive study aimed to evaluate antibiograms from multiple hospitals across the Atlanta metropolitan area. In September 2019, flagship hospitals of five different health-systems within metro Atlanta were surveyed using a questionnaire to collect information on basic facility and microbiology laboratory characteristics. Three health-systems responded, providing inpatient antibiogram data from the 2019 calendar year. These data were combined to create a single, cumulative antibiogram with 18 clinically relevant combinations of microorganisms and antibiotics. In total, data from 10 different hospitals were aggregated to create one regional antibiogram. Results: Data from 10 hospitals were combined to create one regional antibiogram with 18 organisms and 21 antibiotics. The overall prevalence of methicillin-resistant Staphylococcus aureus (MRSA) was 45.1% and vancomycin-resistant Enterococcus (VRE) was 15.8%, carbapenem-resistant Acinetobacter baumannii (CRAB) was 13.2%, carbapenem-resistant enterobacterales (CRE) was 1.1%, and carbapenem-resistant Pseudomonas aeruginosa (CR-PA) was 13.3%. Carbapenem resistance rates were compared between carbapenem-restrictive (n=4) and carbapenem-non-restrictive (n=2) hospitals. The prevalence of CR-PA was significantly higher in carbapenem-non-restrictive hospitals compared to carbapenem-restrictive hospitals, 19.6% vs 11.6% (p < 0 .001). Conclusion: The development of a regional cumulative antibiogram to capture resistance patterns of targeted pathogens across multiple health-systems in a large metropolitan area is feasible. Data from a regional antibiogram is useful in assessing susceptibilities and can serve as a valuable antimicrobial stewardship tool for institutions without access to their own specific antibiogram. Additionally, implementation of targeted stewardship policies, such as carbapenem restriction, demonstrates promise to potentially slow the development of resistant pathogens, thereby improving patient outcomes.

Background: Admission screening for CRO carriage may prevent transmission, but there is a lack of consensus on the best targeted approach. Using a well-characterized cohort of medical intensive care unit (MICU) patients prospectively screened for CRO carriage at time of admission (MAriMbA cohort), we compared the effectiveness of common targeted strategies (singly and in combination) available to hospitals in Illinois to identify MICU patients at risk for CRO carriage, including: (a) screening patients transferred from external facilities (e.g., short- and long-term acute care hospitals); (b) screening patients with a tracheostomy or pressure ulcer; or (c) querying the Illinois XDRO registry for prior CRO history. Methods: Results of rectal swab samples collected within 48 hours of MICU admission during 1/2017-1/2018 and cultured for CROs (carbapenem-resistant Enterobacterales [CRE], CR Pseudomonas aeruginosa [CRPA], and CR Acinetobacter baumannii [CRAB]) were used as the reference standard. Patients’ status as direct transfer from an external healthcare facility and presence of tracheostomy or pressure ulcer were collected prospectively during the MAriMbA study. History of CRO colonization before MICU admission was queried retrospectively from the Illinois XDRO Registry (xdro.org), with the limitation that most reports available during the study period were restricted to CRE. We evaluated each predictors’ independent association with admission CRO status and combined variables in a planned logistic regression modeling approach. Results: CRO colonization was detected in 37 (2.6%; including 26 CRE, 10 CRPA, and 1 patient co-colonized with CRE and CRAB) of 1,423 unique MICU admissions. For univariate analyses, presence of a tracheostomy (OR 9.32, 95% CI 4.29-20.27), presence of pressure ulcer (OR 3.07, 95% CI 1.42-6.64), transfer from an external healthcare facility (OR 1.97, 95% CI 1.02-3.82), and prior CRO history reported to the Illinois XDRO Registry (OR 72.96, 95% CI 25.83-206.07) were associated with higher odds of CRO colonization. A model combining these variables improved the predictive capability (AUC 0.73) (Table). Prior CRO history reported to the Illinois XDRO Registry identified 27% of CRO cases, with number needed to screen (NNS) of only 2 patients. Adding tracheostomy, pressure ulcer, and external facility transfer together improved detection of admission CRO cases to 68%, with NNS of 20 patients (Figure). Conclusion: In a region with well-established inter-facility communication of CRO history via the Illinois XDRO Registry, the addition of screening patients with a tracheostomy, transfer from an external facility, or pressure ulcer may improve early identification of CRO carriage at time of MICU admission.

Background: Nebraska (NE) Infection Control Assessment and Promotion Program (ICAP) is supported by the Nebraska DHHS Healthcare-Associated Infection (HAI) program via a CDC grant and works to assess and improve infection prevention and control (IPC) programs in all types of healthcare facilities. CDC recommends that outpatient healthcare facilities (OHFs) develop and maintain IPC programs; however, littleis known about the infrastructure of IPC programs in OHFs. NE-ICAP performed onsite assessments to review the implementation of best practice recommendations (BPRs) in these programs. Method: Onsite IPC assessments were conducted in OHFs from January 2020 to February 2024. The assessment questions were based primarily on the CDC 2016 Infection Control Assessment and Response (ICAR) tool, complemented by the CMS Hospital Infection Control Worksheet. Assessments included interviews and onsite observations. A total of 66 BPRs were assessed for implementation. Descriptive statistics were calculated using Microsoft Excel for assessment responses and demographic information. BPRs were classified based on hospital affiliation, accreditation status (based on certification by recognized accrediting bodies), and urban-rural designation (based on USDA rural-urban commuting area codes). The chi-square test for independence was performed in SPSS 20 to assess for statistically significant differences across these categories using a threshold of p < 0.05. Result: A total of 19 OHFs had onsite assessments. 42.1% had external accreditation, 77.8% had at least one individual trained in infection prevention regularly available, and 36.8% were considered urban (figure 1). Domains with the lowest compliance (percentage of BPRs in place) included injection safety (48.8%), device reprocessing (49.7%), and personal protective equipment (51.8%). Notable BPRs associated with less than 35% compliance are listed in figure 2. Accredited facilities demonstrated greater compliance with BPRs related to device reprocessing. Conclusion: Important IPC gaps exist in OHFs. Onsite assessments are crucial for evaluating IPC program infrastructure and highlighting areas for improvement. Further studies are needed to understand why accreditation is associated with better compliance with BPRs and the factors contributing to its success.

Introduction: Dust burden in healthcare institutions has been associated with invasive fungal disease (IFD) causing significant morbidity and mortality in immunocompromised patients. Systematically evaluating the impacts of architectural changes on air particulate concentration (APC) could identify risk reduction strategies.

Objectives: We estimated changes in APC in units adjacent to a temporary hard physical barrier in a previously open hospital space after its erection. We propose a model for evaluating the impact of temporary architectural alterations on APC in healthcare settings. Methods: Barriers were erected in an open area of a hospital for four weeks. The barrier partitioned the oncology floor from the atrium, which houses the emergency department waiting area. Continuous APCs were measured in multiple locations before and after the barrier was erected. We conducted an interrupted time series on the daily mean and maximum APCs, excluding the period the barrier was being installed. As a control, the same analysis was conducted on a remote location of the hospital. Results: A topographical representation of the impacted area is included in Figure 1. Regions A and B are in hallways, adjacent to the barriers, and region C is in a patient care area, separated from the barriers by an automatic door. The control region was the cafeteria, which is separated from the barrier space by several hundred feet. After barrier creation, there was an immediate APC reduction in region A from the predicted mean APC of 2µg/m3 to 1µg/m3 (difference of 0.8 µg/m3, p=0.01) (Figure 2). While the barrier was in place, there was a significant reduction in APC in region A by 0.01µg/m3 per day (p < 0 .001). There was no significant change in APC in regions B and C after the barrier was erected and while it was in place. In the control region, there was no significant change in APC at barrier placement nor afterwards. There was no change in the maximum APC at any of the measurement locations. Discussion: Our analysis demonstrated a change in APC at an adjacent area following erection of the barrier; however, APCs were not significantly changed in patient areas. This model could help objectively evaluate changes in particulate concentration. While this analysis cannot predict changes in IFD incidence, it could inform whether permanent architectural changes might reduce APC. Conclusions: We propose a model to evaluate changes in APCs from temporary architectural changes, which could inform permanent architectural changes.

Background: Surgical site infections (SSIs) are a serious complication following surgery. The emergence of multidrug-resistant pathogens has diminished the effectiveness of traditional antimicrobials necessitating a new approach to prevention and treatment. We are developing an innovative device (xIP) that uses UV-C to inactivate pathogens in surgical incision sites, mitigating the risk of developing an SSI.

Irradiation in the UV-C range (200-280 nm) is known to inactivate surface and airborne pathogens by damaging nucleic acids. However, there is a limited research on its effectiveness for surgical sites. Methods: A Krypton-Chloride Excimer (KrCl*) lamp (λpeak = 222 nm), a pulsed Xenon (PX) emitter (broad spectrum), and a UVC LED (λpeak = 282 nm) were evaluated. Inactivation of E. coli ATCC 29425 and MRSA USA300 was determined by in vitro exposure to UV-C at doses of 0 (control), 2, 5, 10, 15, and 20 mJ/cm2. Dosing was controlled by measuring irradiance (mW/cm2) from each lamp and calculating the time to reach desired exposure levels.

Microbial suspensions of log-phase cultures were pelletized and resuspended in phosphate buffered saline three times and diluted to 107 CFU/mL. After UV exposure, suspensions were plated on an agar substrate using a grid-based method. After incubating for 48 hours at 37°C, remaining viability was determined. Results: PX and KrCl* emitters exhibited 5+ log reduction for both microorganisms, while LED showed 4 and 4.5 log reduction against E. coli and MRSA, respectively. PX demonstrated the highest inactivation efficiency (log-reduction per unit dose), followed by KrCl* and LED. Conclusions: In-vitro data suggest that surgical sites could be effectively treated in less than a minute with a small hand-held device and in less than 10 seconds with a larger device. Inactivation of MRSA using a superficial wound model in hairless SHKI1-elite mice (Charles River strain code 477) is in progress. In-silico modelling using optical raytracing is in progress to understand the impact of wound and skin micro-environment on the performance of the device. These data will inform ex-vivo testing using porcine or cultured human skin (EpiDerm FT) models to evaluate the performance in different wound types including incisions, abrasions, and burns, as well as the impact of fluids like saline and blood. Development of the xIP device is underway in collaboration with healthcare professionals to produce a product that is effective, fits into current practice, and user friendly. Upon successful completion of a prototype device, clinical efficacy will be explored.

Background: Traditional infectious disease surveillance data have significant lag time limiting their usefulness in infection cluster detection in healthcare settings. Digital twin spatial representation, electronic healthcare data integration and surveillance automation allow for timely cluster detection and facilitate faster outbreak mapping and contact tracing, better informing infection prevention practice. Method: 4-Dimensional Disease Outbreak Surveillance System (4D-DOSS) is an automated infectious disease surveillance system developed in Singapore General Hospital (SGH), a 2000-bed tertiary healthcare institution. Electronic patient data (bed allocation and laboratory test results) are integrated onto a digital twin of SGH, and surveillance algorithms are applied for routine surveillance and contact tracing. 4D-DOSS was operationalized in SGH and National Heart Centre Singapore (NHCS) on August 1st, 2024. Active surveillance for carbapenemase producing enterobacterales (CPE) in SGH and NHCS includes contacts of inpatients with CPE carriage. Contact tracing for CPE is done on 4D-DOSS. Primary and secondary contact tracing are algorithmically automated. Spatial and temporal patterns are analyzed to understand transmission networks in outbreaks. Automated email alerts can be sent to clinicians to notify significant test results. Results: Contact tracing typically takes two hours per index patient using traditional methods. Contact tracing for CPE using 4D-DOSS takes five minutes per index patient, and multiple index patients can be traced per trace. Based on about 50 COVID-19, CPE and VZV combined exposure events per week in 2023, at 1.92 hours saved per exposure event, there would be a saving of 648 FTE per year, Between August 1st, 2024 and December 31st, 2024, there were eight VRE, eight CPE and 17 acute respiratory viral infection (RVI) clusters in inpatient wards. Selected clusters were viewed during weekly epidemiology rounds to get a better understanding of the transmission network. Outbreak mapping of infection clusters using traditional methods can take up to two days whereas each cluster can be analyzed in 4D-DOSS in under one hour. If four outbreaks are mapped per year, at 47 hours saved per outbreak mapped, the estimated FTE saved is 24 per year.

4D-DOSS has been configured for email alerts for acute RVI in patients in a selected ward since the last week of December 2024. Seven alerts were received in the first week of implementation. Conclusion: The comprehensive digital twin-enabled infectious disease surveillance platform enabled an efficient contact tracing and outbreak mapping system and automated surveillance alerts facilitating timely infection prevention measures. This can potentially improve patient outcomes.