Background: The pharmaceutical industry is estimated to have a larger environmental footprint than the automotive industry. Discarded and unused doses of pharmaceuticals generate financial waste and pollution, and exacerbate antibiotic shortages. The antibiotic daptomycin is dispensed in standard-sized single-use vials and dosed based on patient weight. Residual daptomycin in the vial after dose preparation must be disposed of and cannot be used for another patient. We hypothesized that daptomycin dosing nomogram use would reduce daptomycin waste, environmental impact, and financial costs. Methods: We performed a retrospective chart review quantifying daptomycin waste, defined as disposed of unused daptomycin, at Harbor-UCLA Medical Center, a 400-bed Level 1 Trauma Center, from 1/1/2023 to 12/31/2023. We then adjusted dosing using a daptomycin dosing nomogram. We modeled the difference in daptomycin waste (mg of daptomycin disposed of unused), pharmaceutical waste (weight of excess daptomycin vials required due to wasted antibiotic), and cost between the two dosing strategies. Our model assumed a daptomycin vial weight of 16.8g and cost of $30 per 500mg daptomycin vial. We conservatively estimated pharmaceutical waste as waste only from daptomycin vials, ignoring all other supplies and materials necessary to prepare daptomycin. Results: During the 1 year time period at our Medical Center, 138,882mg daptomycin was wasted. This level of daptomycin waste equates 4671g excess pharmaceutical waste and $8332 spent on unused, discarded daptomycin. In our model, we found that nomogram implementation would have reduced mean monthly daptomycin waste from 11,002mg to 1387mg (p<0.001). This reduction would have decreased the proportion of daptomycin wasted from a mean of 19% to 3% of all consumed daptomycin (Figure 1). Nomogram use would also have saved $7333 and averted 4111g of pharmaceutical waste in 2023. Conclusion: A daptomycin dosing nomogram would have prevented 122,322mg of daptomycin from being wasted and saved over $7000 at a 400 bed Medical Center over one year. Given the 4111 g of pharmaceutical waste is a conservative estimate, and ignores waste from other supplies/materials as well as upstream waste and emissions from daptomycin manufacturing, the overall generated environmental impact prevented by nomogram use is likely significantly higher. Our findings demonstrate that intentionally designed dosing strategies aimed at reducing drug waste can save hospital costs and reduce the environmental footprint of clinical care. When implemented at large health systems these strategies are likely to result in substantial cost savings and reduction in the negative environmental impact associated with pharmaceuticals.

Background: According to the Centers for Disease Control and Prevention (CDC), carbapenem-resistant Enterobacterales (CRE) are an urgent public health threat. The CDC states the most common or ‘Big Three’ CRE are Escherichia coli, Enterobacter species, and Klebsiella species. States look at the ‘Big Three’ for guidance when setting reportable condition criteria for CRE. Evaluating trends of the non-‘Big Three’ genera is critical to ensure surveillance efforts are focused on priority targets. Thus, CRE genera trends were evaluated to verify the fitness of CRE surveillance reporting recommendations. Method: The Antimicrobial Resistance Laboratory Network (ARLN) Southeast region (SER) includes Alabama, Florida, Georgia, Louisiana, Mississippi, Tennessee, and Puerto Rico. All CRE is reportable in Tennessee (TN) and isolate submission is required to ARLN. Other jurisdictions submit CRE to the TN regional lab. Submitted CRE cases to ARLN from 2018 – 2023 were analyzed. CRE cases were defined as an Enterobacterales organism resistant to one or more carbapenem, excluding imipenem for Proteus sp., Providencia sp., or Morganella sp. due to intrinsic resistance. Data was cleaned in SAS v9.4 to provide descriptive CRE statistics. Result: The top three genera for TN fluctuate between Enterobacter sp., Klebsiella sp., Proteus sp., and Escherichia sp. In 2022, Proteus sp. (n=132) had twice the incidence of Escherichia sp. (n=65) in TN. There was an overall increasing trend of Proteus sp. from 2018 – 2023. The largest increase of Proteus sp. in TN was seen between 2018 (n=23) and 2021 (n=183). However, the prevalence sharply decreased between 2021 (n=183) and 2023 (n=12). Proteus sp. was 17% (n=627) of all CRE cases (n=3625) in TN from 2018 – 2023, while the “Big Three” was 72% (n=2628). In contrast, Proteus sp. was only 3% (n=35) of all CRE cases (n=1400) in the SER excluding TN from 2018 – 2023, compared to 89% (n=1250) for the “Big Three”. Conclusion: CRE surveillance identified an increased overall prevalence of Proteus sp. in TN between 2018 and 2022 despite not being included in the ‘Big Three’. While there was a large increase of Proteus sp. observed in 2021, the increase was limited to TN, and the subsequent decline suggests this is an outlier. Jurisdictions outside of TN often only submit Carbapenemase-producing CRE to ARLN as not all jurisdictions have CRE as a reportable condition. Results of this analysis suggest the SER should continue to monitor CRE and Proteus sp. to note if there is an increasing overall trend to better inform isolate submission strategies.

Background: Duplicative laboratory testing is prevalent in health care. Prior research surrounding repeat urine cultures showed that when a negative index culture is repeated within 48 hours, less than 5% of repeat urine cultures show a new bacteriuria. We evaluated the diagnostic yield of repeating urine cultures at longer time intervals, and of repeating a positive urine culture. Methods: We conducted a retrospective study of adult inpatients at Stanford Healthcare who had more than one urine culture collected during hospitalization between January 2023 and February 2024. We included urine cultures that were collected with or without urinary catheters; nephrostomy tubes were excluded. Urine cultures were classified as index or repeat. We analyzed the diagnostic yield of the repeat urine culture, defined as the percent of repeat urine cultures that detected a new bacteriuria not detected in the index culture. Bacteriuria was defined as growth of a bacterial species in quantities >100,000 CFU/mL. A negative urine culture was defined as one that did not have bacteriuria meeting this threshold. Sensitivity analyses used a threshold of 10,000 CFU/mL as the threshold for significant bacteriuria. Results: Overall, 6,955 urine cultures were performed from 6,058 patients. Of these, 864 (12%) urine cultures were repeats. Of the 864 index cultures, 75% were negative. The median time to repeat urine culture was 4 days. When negative index cultures were repeated at 0-3 days, the diagnostic yield for detecting a new bacteriuria was only 9%. Diagnostic yield at 3-6 days was 10%, not significantly higher compared to 0-3 days (p=0.620). Diagnostic yield at 6-9 days was 19%; this increase was significant compared to the 0-3 days group (p=0.014). When positive index cultures were repeated at 0-3 days, the diagnostic yield for detecting a new bacteriuria was only 8%. Diagnostic yield at 3-6 days was also 8%. Yield increased significantly to 15% at 6-9 days from index culture (p=0.013). When the threshold for significant bacteriuria was adjusted to 10,000 CFU/mL, more bacteriuria was detected overall, but primarily of gram-positive organisms. Whether the threshold for significant bacteriuria was 100,000 CFU/mL or 10,000 CFU/mL, the rate of detection of new gram-negative bacteriuria was similar, and remained less than 10% until 6-9 days from index culture (Figure 1). Conclusions: Among inpatients, most urine cultures repeated at less than 6 days provide redundant information. This unnecessary retesting offers an opportunity for diagnostic stewardship.

Background: In children, penicillin allergy labels (PALs) are pervasive and persistent, despite linkage to suboptimal antibiotic selection with higher risk of side effects, increased length of hospitalization, and increased risk of harm throughout life. Up to 10% of children are labeled with PALs, yet over 95% tolerate the medication when tested. Parents might not always know that PALs are over-reported or incorrectly diagnosed. We aimed to examine parent and guardian perceptions of PALs and their attitudes towards delabeling. Method: We invited all English and Spanish-speaking parents of children presenting to two pediatric primary care locations in the northeast U.S to participate in an online, investigator-developed survey. Survey recruitment was passive, with parents discovering the survey through English and Spanish posters in the waiting and examination rooms. The survey included an initial screening question to identify whether a penicillin allergy was present. If the parent answered “yes,” they were instructed to proceed with survey completion. The survey consisted of 32 questions (7 reaction history, 9 perceptions, 5 provider interaction, 4 general knowledge, 6 demographics and one open-ended). We used descriptive statistics to analyze the data. Result: After screening, we received 54 completed responses. Most respondents had a college degree or higher (75%). When asked about the reaction, the majority occurred in those ≤ 2 years of life (55%); the predominant symptom reported was rash (92%). Twenty-nine percent of patients were evaluated in an urgent care or emergency room. Parents reported being very concerned by the reaction to penicillin (79%). When asked if their child would have a reaction if re-prescribed penicillin, none disagreed. Only 38% did not think allergies were permanent. Most families had not been offered penicillin testing (82%), although 67% expressed interest in the testing process, and 64% planned to inquire about testing following our survey. The majority (89%) would not agree to removing PALs without testing, citing fear that the child would have an allergic reaction if given penicillin (60%) and needing more information (25%) as the reasons for lack of agreement with PAL removal without testing. Conclusion: Among this highly educated population, parents expressed concerns at the initial reaction, perceived the reaction would reoccur with future penicillin use, and stated interest in testing, but were reluctant to delabel from history alone. Parents are untapped partners in delabeling; interventions are necessary to enhance parental understanding of the impact of PALs and the potential for delabeling with low-risk allergies.

Background: Serratia marcescens, a recognized environmental pathogen, often contaminates hospital water systems. Infections are typically exogenous, with occasional human reservoirs. NICU outbreaks can result in serious nosocomial infections, including meningitis, bacteremia, and conjunctivitis. Sources include contaminated medical devices, solutions, and hospital water systems, specifically sink traps and outlets, with transmission occurring directly or indirectly via aerosolization. Outbreak Description: Between June 2023 and December 2024, an outbreak of S. marcescens occurred in our hospital’s neonatal facility (Figure 1). The facility has 3 main halls - the NICU, intermediate, and “cradle” rooms, along with a breastfeeding, medication, and incubator cleaning room, containing 17 sinks in total (Figures 2 and 3). The outbreak was identified following two Serratia bacteremia cases in early 2024 and a retrospective review revealing 8 positive ocular cultures since mid-2023. After initiating the outbreak investigation, enhancing infection control measures, and conducting engineering repairs, the case rate decreased significantly. However, three additional bacteremia cases, and a urine culture, were subsequently identified. Infection Control Measures: Control efforts targeted two reservoirs: patients (via healthcare worker transmission) and the environment. Key measures included reinforcement of hand hygiene, aseptic breastfeeding techniques, contact precautions, and environmental disinfection protocols. Bathing was standardized using sterile water. Environmental Sampling and Investigation: Given Serratia’s known association with waterborne contamination, environmental sampling focused on sink traps and outlets across all areas, revealing persistent contamination despite repeated treatment with concentrated chlorine (Table 1). Epidemiological data identified temporal and spatial correlations between contaminated sinks and clinical cases, notably involving faulty plumbing adjacent to NICU sink 3/4 (Table 2). Water leakage and back pressure from a blocked pipe were hypothesized to cause aerosolization from the connected sink causing infections. Microbiological biotyping clustered clinical and environmental isolates, further implicating aerosolized contamination, including from a sink in the incubator cleaning room used to dispose of hospital wastewater (Figure 4). Outbreak Control: Despite pipe repairs and decontamination, sink contamination recurred due to Serratia’s ability to colonize biofilms in water pipes. Expert consultation emphasized “sink hygiene,” including minimizing equipment storage near sinks, distancing neonates and incubators, and avoiding procedures adjacent to sinks. Outcome: This multifactorial approach significantly reduced clinical cases. Continuous environmental monitoring and education aim to eliminate Serratia as a recurring threat in our neonatal facility and broader hospital environment. Conclusion: This outbreak highlights the challenges of controlling waterborne pathogens in hospital settings and underscores the importance of combining engineering, environmental decontamination, and behavioral interventions to

Background: Procedures performed at Ambulatory Surgical Centers (ASCs) have increased over the last decade in the United States. In Tennessee, surgical site infection (SSI) outbreaks in ASCs have been increasingly detected. Still, there is no mandated SSI reporting for ASCs through the National Healthcare Safety Network (NHSN) as there is for Acute Care Hospitals (ACHs). In 2023, the Tennessee Department of Health’s Healthcare-Associated Infections (TDH HAI/AR) program responded to an outbreak of 14 nontuberculous mycobacteria (NTM) periprosthetic joint infections at an ASC. Despite extrapulmonary NTM being a reportable condition in Tennessee, detection of this outbreak was delayed due to gaps in reportable conditions practices at this ASC. Here, we evaluate how NHSN reporting could have impacted the surveillance and detection of infections for this investigation. Methods: Extrapulmonary NTM cases were detected through clinical laboratory and provider reporting. Chart abstractions were performed for cases by HAI/AR epidemiologists using a tool adapted from the Centers for Disease Control and Prevention (CDC). Infections were evaluated using standardized 2023 and 2024 National Healthcare Safety Network (NHSN) definitions depending on the infection date of event. Results: Initial reporting of cases was as mentioned above, resulting in five cases reported together in June 2023, two months after the first positive specimen. Eight (57%) cases met the NHSN definition for Surgical Site Infections (SSIs); four (29%) cases met the criteria for Deep Incisional SSIs, and four (29%) met the Organ/Space SSI. Six cases (43%) were not detected within the 90-day surveillance window; however, three of these cases had documented evidence of superficial infection within those 90 days. Conclusions: Despite its slow infection progression, most NTM infections in this outbreak would have been detected through NHSN surveillance. Even in cases where NHSN SSI criteria were not met, reviewing records and entering data within the NHSN framework may have facilitated faster facility-level detection. Although the nature of NHSN reporting is not suited for rapid detection of outbreaks, the standardized definitions, regular records reviews, and established data entry system would benefit ASC surveillance such as the facility described here, which had no formal mechanism for tracking infections. Additionally, the collection of summary data required through NHSN would better identify reporting gaps prior to outbreak occurrences. The availability of SSI data for ASCs would help public health authorities identify and assist facilities in assessment and prevention activities. Patient safety would thus likely benefit from enhancing surveillance of ASCs through voluntary or

Background: Since 2013, the Australian Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) has provided a standardized framework for hospitals to assess the quality of antimicrobial prescribing. As part of the program’s continuous quality improvement, a revised appropriateness algorithm was developed and is scheduled for implementation in 2025. This study aims to validate this algorithm by evaluating accuracy and inter-rater reliability (IRR) in assessing guideline concordance and appropriateness. Methods: A prototype of the revised assessment algorithm was developed using Qualtrics®, including an assessment of antimicrobial-level guideline concordance, appropriateness and reasons for non-optimal prescribing, as well as overall indication-level guideline concordance and appropriateness. An eLearning module was developed to ensure consistency of training for assessors. Fourteen clinical vignettes (ten general and four specialist) across a range of real-world clinical scenarios and with varying levels of complexity were developed. Gold standard assessments were determined by an independent group of infectious diseases (ID) and antimicrobial stewardship (AMS) clinicians. Existing Hospital NAPS users were invited to participate. General vignettes were split into two equal groups and assigned to assessors in an alternating manner. Those with expertise in haematology/oncology or paediatrics were assigned additional specialist vignettes. Results were analyzed for accuracy against the gold standard, and for IRR using Fleiss’ Kappa coefficient. Results: A total of 102 assessors, across a range of professions, remoteness areas and years of auditing experience, completed their assigned vignettes. Assessors correctly identified the antimicrobial regimen for auditing in 91.9% of assessments, with incorrectly identified assessments excluded. A total of 681 antimicrobial-level and 534 indication-level assessments were analyzed. Figure 1 summarizes the accuracy and IRR for the main outcome measures of guideline concordance and appropriateness. Accuracy and IRR were higher for appropriateness compared with guideline concordance, and at the overall indication-level compared with the antimicrobial-level. Auditors correctly identified all gold-standard reasons for non-optimal prescribing in 68.3% of assessments. Across all measures, accuracy and IRR was higher amongst assessors with specialist ID/AMS experience compared to those without, from metropolitan compared with regional settings, and amongst those with 4 or more years of auditing experience. Pharmacists without ID/AMS expertise scored as highly as doctors and pharmacists with ID/AMS expertise. Conclusion: The revised Hospital NAPS algorithm provides a valid measure of guideline concordance and appropriateness. Higher accuracy and IRR were observed for appropriateness compared with guideline concordance, highlighting the importance of appropriateness as a measure for stewardship surveillance in reflecting quality of patient care.

Background: In response to a second multistate extrapulmonary tuberculosis (TB) outbreak in 2023, linked to contaminated viable bone allografts, public health authorities conducted contact investigations (CIs) to assess TB transmission among healthcare personnel (HCP) potentially exposed to contaminated grafts during surgeries or draining infected surgical sites. Method: A HCP-CI was initiated after Centers for Disease Control and Prevention (CDC) notification that three San Diego county hospitals had received contaminated allografts. Healthcare facilities identified and tested HCP potentially exposed and reported results to the health department. We reviewed the CI processes of each facility and outlined challenges encountered and solutions implemented. Result: HCP-CIs were conducted at five facilities: three hospitals where nine patients received contaminated product; a hospital where revision surgery was performed; and a skilled nursing facility (SNF) that provided postoperative care. We encountered several challenges during the CIs. First, 234 HCPs were potentially exposed based on a framework used in a prior (2021) TB bone allograft investigation. We advised a tiered approach with targeted follow-up of 72 HCP with high-risk exposures (for example, staff directly handling the allograft). Second, the SNF CI was complicated by administrative staff turnover, no SNF point-of-contact, and investigations involving different HCPs during three separate admissions. Substantial public health resources were required over 7 months, including a site visit to interview HCP with positive TB tests and obtain accurate CI information. Third, obtaining CI data was slow and inconsistent. Reasons included lack of a standardized data collection tool during the initial phase of the CI, fragmented information gathering across clinical departments within facilities, lack of responses from licensed practitioners who were not employees (e.g., physicians), variability in notification of exposed HCP for testing, and follow up of HCP that weren’t tested. HCP-CI results were not readily available when requested, leading to confusion, repeated requests, and duplication of efforts. We countered these challenges by leveraging established (or new) relationships with facility leadership and involving multidisciplinary staff to obtain results. Public health recommended facilities contact non-responsive practitioners with high-risk exposures by certified letter notifying them of the exposure and testing recommendations. Conclusions: Close collaboration, communication, and coordination between public health and each healthcare facility’s clinical services and leadership were critical in this HCP-CI. Utilizing a tiered approach streamlined the CI. This complex HCP-CI spanned multiple facilities and could have benefited from early identification of consistent points-of-contact at each facility and use of a standardized data collection tool.

Background: Candida auris(CA) first recognized in the US in 2013, can be resistant to all major antifungal agents limiting treatment options. To decrease its spread, guidelines indicate patients with CA, if admitted to hospital, should be placed in isolation and considered positive indefinitely. Screening around newly identified patients is recommended. Methods: We review CA history in our facility, including colonizations, infections and screening/isolation protocols from 2019-2024. Results: In late 2019,a patient with a CA infection was transferred to our hospital. It was late 2022, before two additional patients with CA were admitted to our faciility from a long-term acute care facility (LTAC) that had a newly recognized CA cluster of cases/colonizations. Screening in our facility did not identify additional cases/colonizations (n =49) at that time. Patients with known infection or colonization were placed in contact isolation. Additional LTAC/LTCFs were recognized from which patients with CA were routinely identified and admitted to our facility Patients from these facilities were deemed high risk (HRP) and were preemptively placed in isolation and screened for CA. From March, 2023 through August 2024,patients with CA or HRPs were placed on a cohorted ward in contact isolation. Cohorted isolation was continued on high risk but screening negative patients until three screening tests were negative and they were no longer at the high risk LTAC/LTCF. Providers were notified by email or through electronic record of patients status and reminded of infection control measures to follow. Any patient with CA had their electronic record flagged for contact isolation in the event of readmission. Screening specimens for colonization were sent to an outside laboratory until August, 2024 when in-house testing became available. With in-house testing, screening results became available in 1-2 days rather than 3-4 days. A new protocol was started and only placed patients with known positive cultures in the cohorted ward. (see image) HRPs are placed in isolation wherever in the hospital they are admitted until screening results are known. If results are positive for CA they are transferred to the cohorted ward. Additionally rooms are cleaned with appropriate disinfectants for surfaces and floors. From December, 2022, through August, 2024 we identified 22 unique patients with cultures from clinical isolates. Specimens included nine cultures from blood, including three of hospital onset. Three cultures were from wounds, one was hospital onset. Other cultures were 1 from bone, 1 from pleural fluid and 9 from urine. 106 patients were identified as colonized with screening. Conclusion: Screening, isolation and cohorting have all been tools for managing CA in our facility. Only three hospital onset CA bacteremias have been identified with those protocols.

Background: Candida auris is an emerging multidrug-resistant fungus recognized as a global health threat. Despite increasing rates of colonization, no standardized protocol exists in the United States for C. auris screening upon admission. In February 2023, the University of Kentucky Healthcare (UKHC) implemented a targeted C. auris screening system for select high-risk patients. Methods: This retrospective observational study was conducted at UKHC, a 1,086-bed academic medical center, using data from patients aged ≥18 years screened for C. auris between July 1, 2021, and June 30, 2024. Prior to February 2023, C. auris screening occurred only during outbreak investigations. Post-implementation, screening was expanded to include ICU admissions, patients from external facilities with wounds or tracheostomies, and patients with a history of carbapenem-resistant organism infection. Axillary and groin swabs were tested via polymerase chain reaction (PCR). Cases were classified as community-onset (CO) Results: Of 13,642 C. auris tests performed, 70 positive cases were identified: 13 cases (6 CO, 7 HO) pre-implementation and 57 cases (31 CO, 26 HO) post-implementation (Figure 1). The mean age was 60.24 years, and males comprised 57.75%. The monthly positivity rate post-implementation ranged from 0% to 2.18% (with a mean of 0.96%). Among the 70 cases, 10 (14.29%) were classified as clinical infections, and 60 (85.71%) as colonization. The primary indications for C. auris screening included ICU admission (42.86%), point prevalence surveys (17.14%), and admission from external facilities with wounds (5.72%). No significant differences were observed between clinical and colonized cases by age, gender, race, or most other comorbidities. However, clinical cases were more likely to have diabetes (90% vs. 48.33%, p=0.0143) and medical device usage, including tracheostomy (80% vs. 45.00%, p=0.0404), gastrostomy tubes (90% vs. 53.33%, p=0.0293), central lines (60% vs. 41.67%, p=0.2799), and urinary catheters (60% vs. 46.67%, p=0.4348). Among ten clinical cases, seven patients received antifungal treatment. Three patients did not receive any treatment since C. auris was not considered clinically significant. 30-day mortality was higher among clinical cases compared to colonized cases; however, the difference was not statistically significant (30% vs. 25%, p=0.7377). Conclusions: The implementation of a targeted C. auris screening program at UKHC has provided critical insights into epidemiologic trends, patient demographics, and risk factors. Understanding these factors is essential for optimizing infection prevention strategies, refining screening protocols, and informing public health efforts to mitigate the spread of C. auris in healthcare settings.

Background: Immunocompromised patients are at an increased risk of infections. With the introduction of the new Hospital Onset Bacteremia and Fungemia (HOB) quality metric, it remains uncertain whether the incidence would be higher within these vulnerable populations. Additionally, the rate of antimicrobial resistance (AMR), which complicates the infection management, is not completely understood. We aim to provide insights into the incidence of HOB in cancer, transplant and surgical patients as well as challenges posed by AMR. Method: Data from three multi-center retrospective studies are included: 1. Adult patients in 38 US hospitals between October 2015 and June 2019 with a procedure under the National Healthcare Safety Network (NHSN) surveillance for SSI to assess the incidence of SSI and SSI-HOB co-occurrence; 2. Adult patients in 41 US hospitals between October 2015 and June 2019 with DRG for myeloproliferative (MP) cancer, solid tumor cancer, transplant, and non-cancer/non-transplant (“reference group”) to quantify their association with HOB; 3. Evaluation of adult patients in 168 hospitals between April 2018 and December 2022 to assess the rate of AMR pathogens and the proportion of AMR among bacterial isolates in patients with and without cancer. Results: 1.Rate of hospital-reported SSI was 0.15 per 100 admissions and admissions with SSI had significantly higher incremental cost ($30,689) and length of stay (LOS) (11.6 days); further, the incidence of HOB was 6-fold higher in admissions with SSI and SSI admissions with HOB resulted in additional $24,586 to cost of care and 6.3 days to the LOS; 2. Rate of HOB in MP cancer was 2-7-fold higher and 57% to 4-fold higher in transplant patients compared to the reference group, depending on LOS. There were no statistically significant differences in the risk of HOB between solid tumor cancer and the reference; 3. AMR pathogen rates were higher in cancer patients than patients without cancer for most pathogen groups, including vancomycin-resistant enterococci (IRR 1.95), extended-spectrum beta-lactamase (ESBL) producers (IRR, 1.48), carbapenem-nonsusceptible Enterobacterales (IRR, 1.46) and multidrug-resistant Pseudomonas aeruginosa (IRR, 1.31). The percentage of nonsusceptible isolates in most pathogen groups was lower in patients with cancer versus without cancer except for ESBL producers among Enterobacterales and vancomycin resistance among enterococci, which were higher in cancer patients. Conclusion: Certain vulnerable patient populations were found to be at greater risk of HOB including those with SSI, MP cancer and transplant patients. The higher incidence of AMR in cancer patients further complicates management of high-risk infections.

Background: Procedures performed at Ambulatory Surgical Centers (ASCs) have been increasing in type and volume for over a decade. Similarly, outbreaks in ASCs are increasingly detected, but ASCs face unique challenges to Infection Prevention and Control (IPC). In 2023, Tennessee state and local health departments (HDs) responded to an outbreak of 14 Nontuberculous mycobacteria (NTM) periprosthetic joint infections in an ASC, unveiling gaps in IPC practice and significant barriers to resolving them. Method: Cases were detected through third-party clinical laboratory reporting. HD Infection Preventionists (IPs) conducted on-site infection control assessments using qualitative observation, verbal interview, and CDC’s Infection Control Assessment and Response (ICAR) and Association of perioOperative Registered Nurses (AORN) checklist tools. A citizen complaint triggered an independent survey performed by the state’s regulatory body. Result: ICAR revealed there was no Water Management Plan (WMP) for the building or ASC suite. Areas with lapses in IPC practice included aseptic technique, instrument handling, and environmental services (EVS). There was no surveillance mechanism for tracking surgical site infections. Complications were tracked via paper provider surveys but could not be produced when requested. Regulatory survey identified additional violations related to biohazardous waste and unlicensed performing of pediatric procedures.

The facility IP and the sterile processing department lacked specialized training in their respective areas. The IP had no knowledge of reportable disease requirements. The outbreak was reported by the clinical laboratory only after five cases had been detected at a separate facility where revisions were performed. Conclusion: Major barriers to IPC best practice included lack of subject matter expertise and the complexity of multi-stakeholder ownership and operation. A healthcare management corporation holding the facility license was responsible for ASC operations, employment of non-physician staff, and adherence to state and federal regulations. An independent orthopedic group employed surgeons, and a third healthcare system owned the building and contracted EVS. As a result, the licensee was not capable of addressing building water management, and the facility IP had no authority over EVS or the physicians’ group to require complications reporting. Public health action was delayed by the ASC not reporting the outbreak, despite NTM being reportable in Tennessee. This delay was likely due to lack of knowledge around reportable diseases and poor surveillance and follow-up. Once all stakeholders met, compliance with recommended interventions improved. Public health authorities should consider supporting ASC IP education opportunities, engaging varied stakeholders during outbreaks, and enhancing surveillance within this setting.

Background: Seasonal viral respiratory pathogens present a significant clinical burden to pediatric patients. During the viral season, hospitals face an increased number of patients requiring isolation precautions. In surveying isolation practices among pediatric institutions, we identified a high variation in interpreting and implementing isolation precautions, including the duration of isolation. This variability resulted in practice challenges articulated by Infection Prevention and Control (IPC) and clinical teams. We sought to simplify and reduce wasteful work processes. Through the initial phase of this quality improvement project, we examined the congruency between isolation orders and signage and the IPC surveillance time needed to modify isolation practices. Method: Our interdisciplinary team developed and created a process map of isolation work processes, identifying at least 7 decision points to place isolation or to de-isolate hospitalized patients. A prioritization matrix was used to select drivers for maximum impact: 1) initiate empiric isolation for the most common viral respiratory pathogens and 2) develop and implement a tool for de-isolation. Improvement measures included isolation order and signage appropriateness (outcome), modifications of isolation orders by providers (process), and IPC time for correcting isolation or providing just-in-time training during rounds (balancing). Both outcome and balancing measures were captured using an investigator-developed survey, which was streamlined 3 times. Comprised of 25 questions, the survey is completed throughout the month by IPC during surveillance and environmental rounds, with collection spanning 2 viral seasons. Descriptive statistics are used to analyze the data for trending and practice modifications. Result: We completed 929 individual observations via survey over 8 months. The appropriateness of isolation precautions orders improved over time, with a shift in the center line (Figure 1). We identified that the rate of appropriateness decreased at the height of the viral respiratory season due to additional precautions (droplet isolation for certain viruses based on the risk of splashes or sprays per our policies). Surveillance time for correcting precaution signs and/or orders decreased from ≥ 15 to ≤ 5 minutes (Figure 2). Conclusion: Automation and use of empiric isolation precautions orders for the most common viral respiratory pathogens in our hospitalized patients has led to a reduction in wasteful workflow processes, minimized decision points, and has decreased IPC time spent correcting isolation orders and signs. In the project’s next phase, we hope to minimize patients’ time in isolation by using a nurse-driven tool to assess their clinical readiness for de-escalation of isolation during their hospitalization.

Background: Hospital outbreak detection depends on microbial cultures that cluster in time and space, generally defined as inpatient units. Data are lacking on whether Emergency Departments (EDs) may be a source of transmission. Objective: Assess ED exposure as a source of transmission using routine whole-genome sequencing (WGS) of bacteria from ED and inpatient specimens in a tertiary academic medical center. Methods: We performed a prospective cohort study of patients at a 450-bed academic medical center who had bacteria isolated from ED and inpatient specimens between April 1, 2022 and March 31, 2023. Each organism per patient specimen was routinely sent for WGS and genomic clusters were identified as two or more bacterial isolates cultured from different patients which were genomically related by WGS, generally, 25 or fewer single nucleotide polymorphisms apart. Retrospective chart review using a standardized assessment form was conducted for patients involved in hospital-onset genomic clusters to assess for epidemiologic links occurring in the ED versus other hospital areas (inpatient or outpatient). Results: During a 1-year period, 3614 isolates were sent for WGS with 44 genomic clusters identified. Thirty (68%) clusters were excluded because they consisted of community-onset cases, suggesting either transmission outside of our hospital or acquisition of a common community strain. Fourteen hospital-onset clusters were evaluated for possible ED transmission. Of the 14 clusters, median cluster size was 2 patients (range: 2-5). Most common pathogens were Enterococcus faecalis (N=4), Pseudomonas aeruginosa (N=3), and Staphylococcus aureus (N=2), with more Gram-positive (N=8) than Gram-negative (N=6) clusters. Nine (64%) clusters had evidence for ED transmission, which were categorized as probable (ED as sole opportunity for exposure, N=5), or possible (ED among multiple healthcare opportunities for exposure, N=4). Examples of ED exposures included (non-mutually exclusive): same ED unit (N=9, 100%), proximal time in ED (≤5 days apart), (N=6, 67%), common ED staff (N=5, 56%). Without WGS, identification of the ED as the probable source of transmission was hampered by the fact that 99% of cultures were taken on different units, with a median time between ED exposure and positive culture of 9 days (range: 0-163). Conclusions: Routine WGS of bacterial isolates in a 450-bed tertiary care center identified 14 hospital-associated transmission events in a year, two-thirds of which were probably or possibly associated with the ED. ED transmission is common but difficult to identify because infection prevention processes rely on positive cultures collected in the same unit close in time.

Background: Pediatric patients with underlying malignancies and hematological disorders, especially those undergoing hematopoietic cellular therapy (HCT) are at increased risk of developing central line-associated bloodstream infections (CLABSI). Despite the long-standing efforts to reduce CLABSI rates, healthcare disparities, particularly in minority populations, continue to contribute to preventable harm. The role of language barriers in CLABSI risk has not been well-explored, especially in pediatric HCT populations. This study aimed to evaluate the association between limited English proficiency (LEP) and CLABSI risk in pediatric HCT patients. Methods: This retrospective cohort study analyzed patients admitted to the transplant and cellular therapy unit of a pediatric oncology center between January 2021 and June 2024. Data collected from the electronic health records included patient demographics, preferred language, underlying primary diagnosis, types and dates of cellular therapy, and central line days (CLD) in the transplant unit. CLABSI events were identified through the hospital infection prevention and control surveillance database and classified as mucosal barrier injury laboratory confirmed bloodstream infection (MBI-LCBI) or non-MBI CLABSI based on NHSN definitions. CLABSI rates were calculated as events per 1,000 inpatient CLD and were compared between patients with LEP (defined as preferred language other than English) and those proficient in English. Multivariate regression model was used to evaluate the independent risk factors for CLABSI. Results: During the study period, 280 patients contributed a total of 12,325 CLD and 93 CLABSI events; of these 57 patients with LEP contributed 3,113 CLD and 29 CLABSI. The crude CLABSI rate in patients with LEP was significantly higher (9.32/1000 CLD) than that in English proficient patients (6.95/1000 CLD) Conclusions: This study highlights the increased risk of CLABSI in pediatric HCT patients with language barriers, the risk of which likely extends beyond this patient group. Addressing these barriers through novel equitable strategies, such as language support services and culturally competent care, is crucial for reducing healthcare disparities, improving clinical outcomes and promoting a more inclusive healthcare environment for diverse patient groups.

Background: The National Healthcare Safety Network (NHSN) Antibiotic Use (AU) Option aids hospital antimicrobial stewardship programs (ASPs) by facilitating tracking and reporting of AU data. In 2021, the Tennessee Department of Health (TDH) launched an AU data quality project to improve reporting accuracy. Quarterly reports are generated, assessing data across 15 quality flags, such as reporting antimicrobial days when days present (DP) are zero or drug-route mismatches. Flags also highlight significant outliers, including DP or AU rates outside the median ±2 interquartile ranges compared to the prior year. Reporting facilities receive actionable solutions for flagged concerns. Method: Data from AU quality flag reports generated by the NHSN AU Option for Tennessee facilities (2021–2023) were analyzed in this cross-sectional study. The analysis summarized the frequency and distribution of flagged issues across facilities and time. Archived data were utilized, excluding updates facilities made after quarterly reports. Quarterly flags per category were calculated for each facility, with total flags compiled annually to determine category frequency and percentage. Additionally, the number of distinct facilities contributing to the annual flag count was evaluated, providing insights into data quality trends across the study period. Result: From 2021 to 2023, 97 facilities submitted data to the NHSN AU Option, resulting in 7336 flags identified in the AU quality reports (Figure 1). The most frequent flag was “location-level AU rate greater than outlying upper boundary” (n=1677, 22.9%), reported by 67 facilities and the highest reported in 2023 (n=722, 23.8%). The second was “location-level DP greater than outlying upper boundary” (n=1588, 21.6%), reported by 68 facilities and highest in 2021 (n=547, 23.5%). The most frequent non-outlier-based quality issue was “antimicrobial days reported for any drug when DP were reported as zero” (n=439, 6.0%) followed by “antimicrobial days for a single drug greater than DP” (n=48) Conclusion: The study reveals data quality concerns in AU reporting among Tennessee facilities. Flags with changes in “Location-Level Days Present” and “AU Rate” outliers being prominent across the study period. These findings underscore the need for continuous monitoring and targeted feedback to enhance data accuracy, as well as a need for antimicrobial stewardship personnel to be able to identify and address changes in prescribing patterns and patient populations efficiently within their facilities. Addressing recurring challenges identified can improve AU data reliability, supporting more effective antimicrobial stewardship and better patient care outcomes.

Background: Gram-positive bacteremia is a challenging cause of morbidity and mortality. Past publications have shown improved patient outcomes and increased adherence to recommended standards of care with infectious disease consultation (IDC) for Staphylococcus aureus bacteremia1. Enterococcus species are another common cause of gram-positive bacteremia with significant morbidity and mortality. This study aims to assess the impact of IDC on the care of patients with Enterococcal bacteremia. Methods: A retrospective chart review was performed on 227 inpatients with at least one blood culture growing an Enterococcus species between June 2022 and November 2023. Patient characteristics collected included age, Charlson Comorbidity index, presence of endocarditis, source of bacteremia, and consultation of the inpatient ID service. Outcomes assessed included in-hospital and 30-day mortality, 30-day re-admission rate, acquisition of repeat blood cultures to document clearance of bacteremia, transthoracic (TTE) and/or transesophageal echocardiography (TEE), and anti-Enterococcal antibiotic duration. Categorical variables were compared with Chi-square or Fisher’s exact tests. Continuous variables were compared with independent t-tests or Mann-Whitney U nonparametric tests. Results: Of 227 patients, 195 (85.8%) received IDC while 32 (14.2%) did not. Patients in both groups had similar Charlson comorbidity indices. 23 (11.7%) patients had Enterococcal endocarditis, all of whom received IDC (Table 1). Patients with IDC had a significantly higher rate of acquisition of clearance blood cultures (98.96% vs. 83.87%, p 76.80% vs. 56.25%, p = .014), and TEE (20.21% vs 0.0%, P = .005) (Table 2). There were no significant differences in in-hospital mortality, 30-day mortality, 30-day re-admission rate, or duration of anti-Enterococcal antibiotics. Conclusions: These results support the conclusion that patients with Enterococcal bacteremia who received IDC were more likely to be managed according to currently recommended standards of care. In this cohort, IDC did not have a statistically significant association with differences in mortality, re-admission rate, or antibiotic duration. Patients with Enterococcal bacteremia are likely to benefit from IDC, especially as they frequently have significant life-limiting co-morbidities complicating their care. References: Vogel M, Schmitz RP, Hagel S, Pletz MW, Gagelmann N, Scherag A, Schlattmann P, Brunkhorst FM. Infectious disease consultation for Staphylococcus aureus bacteremia - A systematic review and meta-analysis. J Infect. 2016 Jan;72(1):19-28. doi: 10.1016/j.jinf.2015.09.037. Epub 2015 Oct 9. PMID: 26453841.

Background: Since the intensive care unit (ICU) is a high-risk area for healthcare-associated infections, effective infection control in the ICU is crucial. Carbapenem-resistant Enterobacterales (CRE) infections have been increasing and have become a significant concern for ICU patients. While CRE colonization does not require treatment, as it represents a carrier state, early detection is crucial to minimize CRE transmission. This study aims to identify the CRE colonization rate and its risk factors in ICU patients to provide a basis for CRE infection control in the ICU. Method: This retrospective cohort study was conducted at a university hospital in Korea from July 2023 to December 2023. Adult patients aged ≥18 years who were admitted to five ICUs (i.e., surgical 1 and 2, medical, cardiopulmonary, and emergency ICUs) and underwent active surveillance cultures for CRE using rectal swabs within 2 days of admission were included. Re-admissions and patients with confirmed CRE prior to admission were excluded. General, clinical, and environmental factor data were retrospectively collected using the hospital’s electronic medical records and nursing documentation system. Multivariate logistic regression was performed on variables with p Results: Out of a total of 1,473 ICU admissions, excluding duplicate admissions, 10 patients with confirmed CRE colonization prior to ICU admission and 722 patients who did not undergo active surveillance cultures within two days of admission were excluded. Among the remaining 741 included patients, 25 (3.37%) patients were colonized with CRE. Klebsiella pneumoniae was the most frequent isolate (n=18, 72%) and 12 patients (48%) were identified as having carbapenemase-producing Enterobacterales. In the multivariate logistic regression analysis, the following were identified as independent risk factors for CRE colonization: age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.01-1.11; p=0.036), admission from other hospitals (OR, 8.77; 95% CI, 2.43-31.59; p Conclusion: Based on the results of this study, early detection of patients with CRE colonization, followed by target screening and proactive infection control measures such as preemptive isolation, could play a key role in preventing the spread of CRE in the ICU.