‘Trade wars are good, and easy to win,’ tweeted Donald Trump in 2018. The US–China trade war that followed proved otherwise – especially when confronting a major economic power. Yet, can trade wars ever be good? While the academic consensus holds they harm all participants, we argue that under certain circumstances they can produce positive outcomes. Set against the backdrop of the Liberation Day tariffs announced on April 2, 2025, this paper examines the limits of the Ricardian free trade model underpinning the current multilateral trading system, identifies when trade wars may serve strategic goals, and explores alternative rules to address state-capitalist distortions without costly, prolonged conflict.

Background: Effective integration of antimicrobial resistant organism (ARO) admission screening into clinical information systems (CIS) can facilitate prompt identification of patients at risk of an ARO and interrupt transmission. However, ARO admission screening remains suboptimal in Alberta, Canada following implementation of the ARO admission screening tool in the provincial CIS. We sought to understand the determinants of adherence with the use of the ARO admission screening tool in the CIS. Methods: A mixed-methods study was conducted using a survey, human factors observations, and qualitative focus groups. Eligible participants included nursing staff and physicians from emergency departments and inpatient units in acute care and acute rehabilitation facilities where the ARO admission screening tool was utilized in the CIS in Alberta, Canada from September 6, 2023 to June 18, 2024 (n=100). A survey (REDCap) explored staff perceptions and experiences using the tool in the CIS. Observations and interviews of nursing staff completing the tool were guided by the Systems Engineering Initiative for Patient Safety model. Virtual (Zoom) semi-structured focus groups explored barriers and enablers of using the tool guided by the Theoretical Domains Framework. Descriptive analysis of survey responses was conducted using Microsoft Excel (Version 2409). Field notes and focus group transcripts were used for a rapid qualitative, thematic analysis. A weaving narrative by theme was used to integrate survey results with findings from the observations and focus groups. Results: There were 527 survey respondents representing all 5 health zones, 5 nurses observed and 20 interviews conducted by the human factors team, and 24 participants in 6 focus groups. Focus group participants represented different sized hospitals (12-1,099 beds) with varying ARO admission adherence rates (29-83%). Three emergent themes arose: context, the ARO admission screening tool, and the individual. Contextual factors included time constraints, increasing nursing workload, competing priorities, lack of patient cooperation, and a need to increase interactions with infection prevention and control programs. Attributes of the tool impacting completion included location of the tool within the CIS, lack of prompts, and multiple sources of information required to complete the tool. At an individual level, themes arose related to experience, perceptions of ARO screening, and lack of training that influenced completion of the tool. Conclusions: Among the emergent themes, multiple determinants were identified influencing the use of the ARO admission screening tool in the provincial CIS. These findings will help inform future strategies to improve ARO admission screening and reduce ARO transmission.

Background: Burn injuries pose a significant risk for infections. Nasal decolonization with mupirocin nasal ointment (MNO) is an established method to prevent infections with Methicillin-resistant Staphylococcus aureus (MRSA). We compared the effectiveness of an alcohol-based nasal sanitizer (ABNS) to MNO against MRSA bacteremia in burn patients. Methods: This was a retrospective before/after study comparing the impact of an MNO (study arm 1; Bactroban 2%, GlaxoSmithKline, NC; application: twice daily for five days after admission) and an ABNS (study arm 2; Nozin, Bethesda, MD; application: twice daily for entire stay on Burn unit) on Healthcare Associated (HA-) MRSA bacteremia events in burn patients. The Burn unit consists of eight intensive care beds for burn care and 15 regular beds in an 885 bed, tertiary care, academic hospital. Inclusion criteria were all burn patients 18 years of age and older admitted under the burn service for more than four consecutive days. No mandatory MRSA screening was performed. Outcome measure was HA-MRSA bacteremia acquired > four days after admission. Patient characteristics included demographics, BMI, intensive care need, MRSA colonization at admission, type and degree of burn, inhalation injury, total burn surface area, Baux score, inpatient mortality, length of stay by total, burn mixed acuity and burn ICU were documented. Daily compliance with treatments was extracted from patient records (EPIC, Verona, WI). Continuous patient characteristics were compared using t-tests or Wilcoxon signed-rank test (for factors with skewed distributions), and chi-square tests for categorical factors. Product-limit time-to-event analysis and log-rank test were used to compare the outcome measure between groups. Results: From 08/01/2021 to 07/31/2024 a total of 920 patients were enrolled (MNO arm: 448; ABNS arm: 462) with 239 and 217 meeting inclusion criteria. No differences in patient characteristics were detected between the two groups at all patients and >80% treatment compliance levels (MNO: 121 encounters; ABNS: 98 encounters). Patients in the MNO arm encountered 14 events compared to one event in the ABNS arm (p=0.0021). The figure displays the product-limit time to event estimates for developing HA-MRSA bacteremia at the >80% adherence level (p= 0.021). Lower adherence levels (50%, 60%, 70%) did not show significance (p>0.05) in the time-to-event analysis. Conclusion: Providing ABNS >80% of the time resulted in a significant decrease in HA-MRSA bacteremia events in burn patients compared to an MNO. The daily application throughout hospitalization may offer additional protection against MRSA in patients hospitalized for extended periods of time.

Background: Outbreaks of Zaire ebolavirus are an ongoing public health threat associated with high case fatality rates. The US Advisory Committee on Immunization Practices (ACIP) recommends preexposure vaccination with rVSV∆G-ZEBOV-GP Ebola vaccine (Brand name: Ervebo), which is effective in preventing disease caused by Zaire ebolavirus, to people at high risk for occupational exposure. We describe the perceptions and desire to be vaccinated with Ervebo among a subset of eligible US healthcare workers (HCWs). Methods: We conducted a cross-sectional online anonymous survey during March-October 2024, distributed to eligible HCWs at three Regional Emerging Special Pathogen Treatment Centers (RESPTCs): NYC Health + Hospitals/Bellevue, University of Texas Medical Branch, and Denver Health & Hospital Authority. Results: There were 66 responses (40% response rate), with the majority aged 30-49 years (63%), female (65%), and either a physician (42%) or nurse (27%). The majority (56%) had received some form of education on Ebola vaccines, most commonly through informational sheets or pamphlets (60%). Thirty-four (51%) were interested in (n=30) or already vaccinated with (n=4) Ervebo. Among those interested or already vaccinated, 44% would choose to receive the vaccine immediately, while 24% would get vaccinated if there were a case of Ebola virus disease (EVD) in the US. Among those not interested or unsure (n=32), most were concerned about risks of spreading the vaccine viral vector (44%), insufficient knowledge about the vaccine (31%), and unacceptable side effects (31%). Among all respondents, the most common concerns about adverse events included potential for a serious side effect (64%) and risk of arthritis (36%). Forty seven percent of respondents were concerned about the potential for spread of the vaccine virus vector. Respondents most frequently wanted more education on potential side effects (67%) and the risk of spreading the vaccine virus vector (59%). Among those not interested in vaccination or unsure (n=32), some may be convinced to accept vaccination if there were an EVD outbreak in the US (44%), if they better understood the risks and benefits of vaccination (34%), and if they better understood the vaccine safety (31%). Conclusion: During a period with no EVD outbreaks, a majority (51%) of eligible HCWs surveyed at three US RESPTCs were interested in or had received Ervebo. A significant proportion (24%) prefer to postpone vaccination until there is a case of EVD in the US. Deployment of Ervebo to eligible US HCWs may be optimized by addressing concerns identified in this study.

Consulting dictionaries during writing requires time and cognitive resources. ColloCaid, a writing assistance prototype freely available online, was designed to minimize the cognitive strain on writers by embedding a collocation database within the writing environment. Usability surveys have shown ColloCaid can indeed help. In this study, we go beyond user perceptions. Using authentic excerpts of student academic writing by 27 advanced L2 English speakers, we analysed (1) the lexical coverage of the tool, (2) the collocation changes prompted by the tool, (3) the reasons behind decisions to revise collocations, (4) the effect of revisions prompted by ColloCaid, and (5) the participants’ perceptions of using the tool to revise authentic writing assignments. Our findings indicate that ColloCaid offered good academic collocation coverage, that the participants tended to accept its collocation prompts with discernment, and that the revisions made resulted in more fluent texts overall.

Background: Surgical Site Infections (SSIs) are a major cause of morbidity resulting in devastating patient outcomes following an Abdominal Hysterectomy (HYST) procedure. No single intervention has demonstrated reduction in SSI rates, however, bundling prevention strategies have demonstrated reduction in SSI. In addition to our organization’s systemwide surgical site infection prevention bundle, we developed a supplemental bundle of focused strategies specific to abdominal hysterectomy procedures, to address a 37.26% increase in Abdominal Hysterectomy Standardized Infection Ratios (SIRs) in 2021. Methods: In 2021, a supplemental hysterectomy specific bundle was developed and implemented in three facilities within our health system that were experiencing increased HYST SIRs. After review of current literature, the following four strategies were included for the supplemental bundle for all abdominal hysterectomy procedures (open, laparoscopic, and robotic); the utilization of 500mg Metronidazole with Cefazolin as part of surgical antimicrobial prophylaxis, for cases where: anticipated bowel involvement occurs and for oncology patients with complex hysterectomies; the use of standardized vaginal and perineal preparation using either chlorhexidine (CHG) or Povidone Iodine (PVI); the use of a separate sterile closing tray; and changing of gown and gloves by surgical team, prior to going to abdomen from vaginal area. Compliance with the prevention strategies were measured during this period and SSI SIRs were reviewed monthly with overall trends monitored. The National Healthcare Safety Network (NHSN) criteria for SSI were used to assess for SSI after hysterectomy. Results: The SIR for HYST procedures in 2021 was 1.083 with 23 SSIs identified from 2339 abdominal hysterectomy procedures performed. Immediately following the implementation of the supplemental bundle at three facilities, the SIR decreased by 39% to 0.661 in 2022 with 11 SSIs identified from 1842 procedures performed. The HYST SIR outcomes were 0.782 in 2023 and currently at 0.979 through July 2024. Compliance during the intervention period ranged from 93.9% to 94.6%, and surgical antimicrobial prophylaxis compliance increased by 4% to 89.35% at these three facilities. Conclusion: Bundled interventions when employed, demonstrate benefit from the synergistic effects of multiple strategies decreasing the outcome rate of surgical site infections as compared to a single intervention. Establishing a standardized abdominal hysterectomy bundle, allows for minimal variation for patients undergoing abdominal hysterectomy procedures when adherence is at its maximum. Our goal is to expand systemwide based upon the successes from the three facilities, to achieve as close to zero postoperative infections by implementing evidence-based practices performed as a comprehensive bundle.

Pyotr Tchaikovsky’s early opera Oprichnik is overdue for rediscovery as one of the composer’s most overt forays into the queer themes that critics and scholars have long appreciated in his mature works. Oprichnik features the composer’s most extensive and provocative employment of travesti in its depiction of a historical figure mostly remembered for his rumoured sexual relationship with tsar Ivan IV. This paper takes a detailed look into this and other queer features of the opera within their cultural, historical and biographical contexts. These contexts, including the development of trouser roles in Russian opera, transformations in public discourse on sexuality and gender, and Tchaikovsky’s relationship with his pupil Vladimir Shilovsky, help bring into focus the special appeal the sixteenth-century Muscovy of Ivan the Terrible and his oprichniki had as a topos for a Russian artist experimenting in the artistic depiction of sexual and gender variance.

Background: Central line associated bloodstream infections (CLABSIs) are a preventable healthcare-associated infection. Evidence shows implementation of evidence-based bundled infection prevention strategies can reduce CLABSIs. We reviewed the impacts of a CLABSI prevention toolkit on CLABSI rates as well as compliance with key prevention practices. Methods: A CLABSI Prevention Bundle Toolkit was implemented in December 2023 at a quaternary care academic medical center. The toolkit delineated the elements of the bundle, including hand hygiene, daily review of line necessity, daily chlorhexidine gluconate (CHG) topical treatment, aseptic technique for insertion and maintenance, along with the responsible party for each task and educational resources for staff and patients. Additionally, the toolkit required weekly audits of CLABSI bundle by individual units and a multidisciplinary meeting to debrief each CLABSI to identify opportunities and successes. Analysis of compliance with key prevention practices, CLABSI rates and clinical details was completed before (December 2022 – November 2023) and after (December 2023 – November 2024) implantation of the toolkit. Results: Compliance with key prevention practices pre- and post-toolkit implementation is detailed in Table 1. There was a 37% reduction in CLABSI rate pre- and post-toolkit implementation as shown in Table 2. Clinical details including CLABSI classification as preventable, end-of-life or definition-based (Hsueh, Maurice and Uslan, ICHE 2022), organism, dialysis, transplant status and patient race are detailed in Table 2. Conclusions: CLABSI prevention bundles have been shown to reduce CLABSI, but implementation and compliance of the bundle can be challenging. A toolkit which outlines required tasks, responsible parties, regular audits and debriefs after CLABSI can help support healthcare teams in successful implementation of the full CLABSI bundle. Following the bundle toolkit implementation there was improvement in rates of CHG treatment and line necessity review with an overall decrease in CLABSI rates. Not all process measures included in the toolkit are able to be quantified so likely additional factors contributed to the reduction in CLABSI rates. Overall, there did not appear to be a difference in the types of CLABSIs, organisms or patient demographics in the pre and post-toolkit groups although there were more CLABSIs in transplant patients post-toolkit suggesting a complex patient population. A comprehensive toolkit can aide in implementation of a multi-faceted prevention bundle, provide a structure for accountability and help improve patient outcomes.

Background: Ventilator associated events (VAE) due to changes in positive end expiratory pressure (PEEP) or fraction of inspired oxygen (FiO2) are associated with adverse outcomes for patients in the intensive care unit (ICU). Accurately identifying VAEs is important to improve the quality of care and outcomes for ICU patients. However, we have identified “false-positive” VAEs that are triggered by stylistic manipulation in ventilator settings, or knobmanship, without “true” VAEs that are preceded by signs of hypoxia. This knobmanship creates an undue burden for Infection Preventionists to differentiate clinically relevant VAEs that impact patient outcomes from “false-positive” VAEs. Methods: We utilized the Center for Disease Control and Prevention’s National Healthcare Safety Network definition to retrospectively identify VAEs in the pre-pandemic and post-pandemic eras. Of the five ICUs monitored for VAEs, the Neurosciences ICU had the greatest number of events in 2022 and 2023. Working with the NSICU, a pilot study using an initial PEEP of 6 millimeters of mercury (mmHg) rather than 5 mmHg for all intubated patients was conducted. We hypothesized that this would reduce the incidence of “false-positive” VAE without causing adverse patient outcomes. Results: Out of 283 reported VAEs from the pre-pandemic period of January 1, 2019, to December 31, 2020, 59 (21%) were due to ventilator changes in PEEP or Fi02 without preceding hypoxia. Post-pandemic evaluation from January 1, 2022, to December 31, 2022, identified “false-positive” VAE in 56 (41%) out of 137 VAE cases. Eighty-two (59%) of the 137 VAE cases were due to changes in PEEP from 5 mmHg to 8 mmHg. After changing the starting PEEP in the NSICU to 6 mmHg from 5 mmHg, from October 1, 2024, to December 1, 2024, only 1 VAE was identified compared to an average of 10 for similar quarters in 2022 and 2023. Despite this change, no adverse events or concerns were noted by the primary ICU team or respiratory therapists. Discussion: With thoughtful changes in knobmanship we reduced the burden of “false-positive” VAE without leading to adverse patient outcomes. Conclusions: Alteration in starting PEEP can reduce the burden of VAE that are not clinically relevant and allow Infection Preventionists the opportunity to critically analyze clinically relevant VAEs to improve ICU patient outcomes.

Background: The prioritization of U.S. health care personnel (HCP) for early receipt of messenger RNA (mRNA) vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) allowed for the evaluation of the effectiveness of these vaccines in a real-world setting among a high-risk population. The purpose of this study was to summarize the sociodemographic characteristics of HCP in Oregon eligible to receive COVID-19 vaccination and estimate vaccine effectiveness (VE) of a mRNA COVID-19 vaccine booster dose. Methods: We conducted a case-control study involving HCP from 5 hospitals in Oregon. Cases were defined as those with a positive antigen test or nucleic acid amplification test (NAAT) for SARS-CoV-2. Controls were defined as those with a negative antigen test or NAAT result and were matched to cases by site and within a 2-week interval of test date. Using conditional logistic regression with adjustment for age, sex, race and ethnicity, educational level, underlying conditions, and reported exposure to COVID-19, we estimated VE for a 3rd COVID-19 vaccine booster dose (with the 3rd dose more than 150 days after the 2nd dose). VE was estimated using the screening method as 1-odds ratio x 100%. Results: Among 865 HCP, 374 (43%) were included as case-participants and 491 (57%) as control-participants. Overall, the adjusted VE of a booster dose was 62.6% (95% CI: 37.6%, 77.6%), compared to vaccination with 2 mRNA doses. Logistic regression analysis indicated that HCP with a college degree (vs. no degree, OR: 3.26, 95% CI: 1.96, 5.45), private insurance (vs. government/military, OR: 3.32, 95% CI: 1.28, 8.59), and an income level $200K+ (vs. <$50K, OR: 3.25, 95% CI: 1.60, 6.60) were more likely to have received the booster vaccine. Conclusions: The mRNA COVID-19 booster vaccines conferred approximately 63% protection against COVID-19 among Oregon HCP and were found to be effective under real-world conditions. These findings indicate moderate initial protection against SARS-CoV-2 infection and encourage remaining up-to-date with subsequent COVID-19 vaccines. The identification of sociodemographic characteristics of HCP who are more likely to have received a booster vaccine provides insight into those at higher risk for adverse COVID-19 outcomes due to lower vaccine coverage. While understanding these characteristics is valuable for directing ongoing vaccination efforts towards these populations, further research is needed to understand the mechanisms that contribute to variations in vaccine uptake.

Background: Most people in the US lack access to infectious disease (ID) expertise, with 80% of counties lacking an ID physician. This is problematic as in-person ID consultation has been shown to improve clinical outcomes such as mortality with certain invasive infections, with Staphylococcus aureus bacteremia (SAB) as the paradigm. Telemedicine consultation has emerged as a tool to expand access in rural and underserved communities though its impact on clinical outcomes is less well established. This study characterizes the impact of a Tele-ID program in improving care for patients with SAB at a network of academic-affiliated rural hospitals that do not have access to in-person ID consultation. Methods: This was a retrospective cohort study of patients with SAB who were initially evaluated at 3 academic-affiliated rural hospitals between 7/1/22 and 6/30/24. A cohort of patients who received a Tele-ID consult was compared against a cohort that did not. The primary outcome was adherence to the standard of care for SAB, defined as documentation of clearance of blood cultures, receipt of an echocardiogram, and receipt of an appropriate course of antibiotics. Secondary outcomes included clinical outcomes such as mortality and readmission rates. Results: A total of 260 discrete episodes of SAB were screened for inclusion, with 122 episodes meeting inclusion criteria. Seventy five patients (61.5%) who received a Tele-ID consult were compared against 47 patients (38.5%) who did not. Patient characteristics were overall similar in these groups, though those receiving Tele-ID consultation were more likely to have end-stage renal disease (15% vs 0%, p < .01) and indwelling hardware (56% vs 21%, p < .01). Tele-ID consultation was associated with a higher likelihood of receiving standard of care for SAB (91% vs 15%, p < .01). This finding was consistent across all hospitals and among the individual components of the primary outcome. In addition, Tele-ID consultation was associated with significantly decreased SAB-related 30-day mortality (7 vs 24%, p < .01) and SAB-related 90-day mortality (8 vs 25%, p < .01). No significant difference was observed in rates of readmission or relapsed bacteremia. Conclusion: In this retrospective cohort study of 122 patients with SAB cared for in rural, academic-affiliated hospitals, Tele-ID consultation was associated with a significantly increased likelihood of receiving standard of care and decreased mortality. This data will inform policy at regional hospitals, such as supporting a mandatory ID consult for SAB and implementation of a SAB bundle.

Background: New York City (NYC) is vulnerable to antimicrobial resistant pathogens given its population density, mobile population of travelers and immigrants, and multiple health systems in close proximity. While some NYC health systems make institutional antibiograms publicly available, it remains challenging for clinicians, antimicrobial stewardship programs, and public health institutions to understand regional antimicrobial resistance trends. Multifacility antibiograms can raise awareness of regional trends in resistance and potentially serve as a benchmark for local facilities. We created and distributed an annual regional antibiogram based on facility-level data from NYC healthcare systems. Method: Using Clinical Laboratory Standards Institute guidance, facility antibiograms for calendar years 2021, 2022, and 2023 were solicited by the NYC Health Department and voluntarily submitted by NYC healthcare systems. NYC regional antibiograms were generated for each calendar year by Firstline (Firstline.org, Vancouver, BC), a vendor with technical expertise in creating multifacility antibiograms. When sufficient data were received and facility confidentiality could be ensured, data were stratified to create additional antibiograms by facility borough, setting (i.e., emergency departments), or patient type (i.e., pediatric patients). Antibiogram data were uploaded to Firstline’s clinical decision support application for patient-facing NYC prescribers. Result: Of 56 NYC hospitals, 45 (80%) submitted antibiogram data during the project period, comprising 19,766/25,929 (76%) of NYC hospital beds. Of these hospitals, 40 (89%) submitted antibiogram data suitable for inclusion in >1 year of the citywide antibiogram (average: 31 hospitals/year). Annual antibiograms were created for Manhattan, Brooklyn, and Queens; insufficient data were received to create borough-level antibiograms for Staten Island (except 2022) and the Bronx. Annual pediatric and emergency department antibiograms were generated from citywide data. Citywide resistance rates for select pathogens and antibiotics appeared stable across the 3 years (Figure 1A-D). Antibiogram data received 417 views on Firstline between November 14, 2023–December 18, 2024. Conclusion: Through voluntary antibiogram submission from health systems, the NYC Health Department generated annual citywide antibiograms that comprised the majority of hospital beds in NYC. We achieved a high rate of voluntary participation because health systems submitted existing institutional antibiograms. Additionally, distributing the NYC antibiogram via a clinical decision support application allowed clinicians to access up-to-date citywide antimicrobial resistance rates in NYC. Despite high participation, differences in data reporting limited our ability to pool antibiograms across facilities (e.g., Figure 1B), reducing representativeness. In future antibiogram iterations, in addition to increasing facility participation, we will explore using susceptibility data electronically reported to the Health Department.

Background: The role of environmental sampling to monitor airborne fungal loads (AFL) in healthcare facilities is controversial due to a paucity of data to guide the interpretation of results. Systematic surveillance for infections that might result from exposure to airborne fungal spores is furthermore limited by the lack of standardized definitions for healthcare-associated invasive mold infections (IMI).

Setting: 490-bed tertiary-care pediatric hospital Methods: Retrospective ecological study of the relationship between AFL and IMI. Volumetric samples for fungal culture from 1000 L of air were obtained approximately monthly from November 2018 through October 2023 with a bioaerosol impactor on units caring for patients at risk for IMI. Fungi in environmental cultures were classified as opportunistic fungal pathogens versus those that are rarely pathogenic. Prospective surveillance was conducted using standard definitions for proven and probable IMI. Cases with symptom onset after one week of hospitalization or in patients with either a previous hospitalization or more than one ambulatory encounter at our facility during the month prior to admission were considered healthcare-associated events. Poisson regression was used to examine the association between AFL and monthly average IMI rates. AFL values were also categorized to analyze the association with IMI rates using the chi-square test for trend. Results: During the period of AFL surveillance, 51 healthcare-associated proven or probable IMI were identified of which 33 were in hematology/oncology patients (including stem-cell transplant recipients) and 7 were in cardiac patients. The median total AFL on occupied inpatient units was 2 CFU/m3, and the most frequent pathogens identified were Penicillium species, dematiaceous molds, and Aspergillus species. No significant association was found between IMI rates and the average house-wide AFL for opportunistic fungal pathogens. The hematology/oncology IMI rate, however, increased by 1.48-fold (95% CI 1.00-2.19, P = .05) in association with an increase of 1 CFU/m3 in the pathogen AFL on units caring for these patients. The local AFL of Aspergillus species demonstrated an even stronger association with the hematology/oncology IMI rate (15.9-fold increase for an increase of 1 CFU/m3 [95% CI 2.8-90.7, P = .002]). The figure summarizes trends in hematology/oncology IMI rates across different ranges of average monthly AFL values. Conclusions: Environmental surveillance for AFL on appropriate hospital units may identify periods of increased risk for IMI among hematology/oncology patients. Additional work is needed to define the role that routine AFL surveillance may serve in infection prevention activities for immunocompromised patients.

Background: Whooping cough, caused by Bordetella pertussis (BP), is a vaccine-preventable illness spread through respiratory droplets. As the disease disproportionally impacts infants and children, vaccination is part of the routine childhood series in Canada. However, vaccine hesitancy and resultant declining rates of community immunity increase the risk of disease. We leveraged our existing wastewater-based surveillance (WBS) network to assess its ability to track clinical disease in response to an outbreak in southern Alberta. Methods: For seven months before and after the declaration of a January 2023 outbreak, wastewater samples were collected at approximately weekly intervals from five municipalities in southern Alberta (~1.05 million residents). 24-hour composite wastewater was pelleted, mechanically lysed, and DNA extracted. B. pertussis gene BP283 was quantified by qPCR and normalized against total-bacterial 16s rRNA. De-identified clinical data was obtained from Alberta Health Services (AHS) and vaccination rates collected from the AHS Interactive Health Data Application dashboard (http://www.ahw.gov.ab.ca/IHDA_Retrieval/). Per local guidelines, cases could be diagnosed through molecular testing, or if an individual had a strong epidemiological link to a known case and compatible whooping cough symptoms (https://open.alberta.ca/publications/pertussis). Cases were mapped to sewershed areas using forward sortation areas. Fishers exact test was used to determine the association of the categorical variables of positive wastewater samples and clinical cases diagnosed in the week following, as well as to compare rates of wastewater positivity before and after the outbreak was declared. Results: Over the study period 296 cases of whooping cough were identified, with 256 after the outbreak was declared. No wastewater samples were positive for BP prior to the outbreak (0%) and 22 were positive during the outbreak (19.8%), p = 0.0006 (Figure 1). Of the positives, the median ratio of BP:16s rRNA was 8.89x10-9 (IQR: 5.31x10-9 to 4.19x10-8). Detection of BP in the wastewater did not necessarily predict the occurrence of cases the following week within individual municipalities, but there was an association when all sites were aggregated (OR 2.47 [CI: 1.01–6.05], p = 0.04). Vaccination rates in the communities ranged from 40.9% to 72.2%, and did not associate with wastewater detected Bordetella pertussis. Conclusion: BP can be detected in wastewater during outbreak periods, though infrequently and in very low concentrations. For WBS to be used as an effective tool to monitor and potentially mitigate cases of whooping cough for WBS (and other respiratory pathogens which are not readily amplified in the gastrointestinal tract), assay sensitivity will need to be improved.

Background: Racial and ethnic disparities have been demonstrated across a range of healthcare outcomes and services, including infectious disease burden. Individuals who reside in communities with increased social vulnerability are more likely to experience worse infection-related outcomes. These disparities are likely exacerbated by structural and systemic inequities experienced during inpatient care, even for common diagnoses, such as urinary tract infections. We explored the relationship between race, population-level social vulnerability, and urine culture results in the inpatient setting. Methods: We conducted a retrospective cohort study at Stanford Health Care from January–December, 2023. We included all adult inpatients who had a urine culture collected. The Center for Disease Control’s Social Vulnerability Index (SVI) was used as a composite measure of social vulnerability. Patient addresses from electronic health records (EHR) were geocoded to determine census tract-level SVI designation using the California-specific SVI database, and out-of-state addresses were excluded. Unhoused patients were identified by a discrete field in the EHR. We included demographics, urine culture results, and time of urine culture collection. Community-associated positive urine cultures were defined by a collection time ≤48 hours from admission, while healthcare-associated positive cultures were collected >48 hours from admission. Results: There were 5,374 admissions with urine cultures collected in 2023. The overall median SVI was 0.34. Compared to the statewide median overall vulnerability of 0.50[IQR: 0.25–0.75], our inpatient population resided in less vulnerable areas. When comparing patients with positive and negative urine cultures, the overall SVI, the four-specific SVI themes and SVI quartiles were similar. Unhoused patients were more likely to have a negative culture than a positive culture. Patients who identified as Asian were more likely to have a healthcare-associated positive urine culture than a community-associated positive culture. Patients who identified as Hispanic were more likely to have a community-associated positive culture than a healthcare-associated positive urine culture. Patients who identify as white or black had similar likelihood of developing a community-associated or healthcare-associated positive culture. Discussion: We did not find any differences in SVI among patients based on urine culture positivity. However, when stratified by community- vs healthcare-associated we found that patients who identify as Asian or Hispanic may be more likely to have a positive urine culture. These differences in outcomes are likely complex and multifaceted, potentially related to various social drivers of health present both before and during admission. Further exploration is needed to understand what is contributing to these findings.

Background: Patient bathing plays a vital role in patient care and cleanliness, as well as in the prevention of infections, assisting in the removal of transient skin flora, which are predominately gram-positive organisms, particularly Staphylococci. However, there are inherent risks that come with the use of water in healthcare facilities, particularly the potential for acquisition of pathogenic bacteria from surfaces by residents. Current cleaning and disinfection protocols encourage the disinfection of the shower facilities in between each patient, but adherence to this practice can be a challenge with the staffing shortages seen in environmental services linked to long-term care facilities. The purpose of this point-prevalence study was to identify Staphylococci contamination in shower facilities at a long-term care and rehabilitation center Methods: Five shower room facilities in a long-term care and rehabilitation center were cultured on one day in July 2024. Five surfaces in the shower facility/room were cultured: the shower bench, the faucet, the floor drain, the grab bar, and the shower curtain. A total of 25 cultures were obtained using sterile transport swabs with liquid Stuart’s medium (Fisherbrand, Fisher Scientific, Suwanee, GA) and immediately placed in ice for transport to a microbiology lab. At the lab, the swabs were plated onto two different agars: CHROM MRSA agar and mannitol salt agar (MSA) and incubated for 48 hours. Plates were then read and assigned a qualitative “Yes/No” value if at least 1 colony forming unit of interest was seen. Results: Of the five surfaces cultured in the shower facilities, the bench shower seats were the most heavily contaminated. All of the bench shower seats tested positive for coagulase-negative Staphylococcus (CoNS) and Staphylococcus aureus (MSSA), and 40% of the bench seats tested positive for Methicillin-Resistant Staphylococcus aureus (MRSA). The floor drains were the second most contaminated surfaces, with 80% of surfaces testing positive for both CoNS and MRSA, respectively. Grab bars were the least contaminated surface examined, with only 40% of surfaces testing positive for MSSA and CoNS. Conclusion: This study showed that there was a high prevalence of Staphylococci organisms in the shower facilities, including showers that were marked “clean”. Finding 40% of shower benches contaminated with MRSA is concerning, particularly for some of the elderly patients using these showers. These findings highlight the lack of adherence to the cleaning and disinfection protocols. Further research should be done if adherence to their protocols will reduce Staphylococci surface burden.

Specialty Infectious Disease physician.

Clinical Associate Professor University of South Dakota Medical School

Consultants for South Dakota Department of Health regarding antibiotic stewardship

Consultants West Virginia Hospital Association regarding antibiotic stewardship Background: An equitable distribution of antibiotic stewardship expertise is a challenge for rural communities across the United States. The advantage rural communities have is that there are fewer barriers for implementation of effective antibiotic stewardship strategies.

The authors worked with several rural communities in the United States over the paste several years implementing a proven antibiotic stewardship strategy that has been shown to decrease Clostridioides infection. Method: Strategy employed was avoidance of the more common microbiome damaging broad spectrum antibiotics in favor of more targeted narrow spectrum antibiotics based on local antibiogram data. Additionally, ongoing infectious disease and antibiotic stewardship access for questions as well as data review with feedback were provided.

Findings: Clostrioides infection was eliminated in some communities and others markedly decreased as shown by a very low percentage of toxin positive, PCR positive to toxin negative PCR positive isolates expected for that region. Conclusion: This strategy is translatable to other communities accompanied by antibiotic stewardship expertise and support and can be a model for community wide antibiotic stewardship which further optimizes patient and resident safety from Clostidioides infection.

Background: Adherence with antimicrobial resistant organism (ARO) admission screening is suboptimal, despite clinical support tools in clinical information systems (CIS) to facilitate the process. Behaviour change techniques to improve adherence are needed. However, in a resource-constrained healthcare system, strategies that motivate healthcare workers (HCWs) to align their practices with infection prevention and control (IPC) policies need to be prioritized. Methods: An online survey (REDCap) and a virtual (Zoom) consensus meeting using a modified nominal group technique with online voting was conducted among HCWs, IPC, and the CIS staff in September and October 2024, respectively, to achieve consensus on a prioritized list of interventions to improve ARO admission screening at acute care and acute rehabilitation facilities (n=100) in Alberta, Canada. Interventions from the Behaviour Change Wheel were mapped to barriers/enablers influencing screening adherence. Each intervention was judged across the APEASE criteria (Acceptability, Practicality, Effectiveness, Affordability, Side Effects, Equity) using a 5-point Likert Scale. Consensus to include interventions required >4 criteria with >80% agreement, consensus to exclude required >4 criteria with 80%. Interventions that did not reach consensus were discussed to determine whether to include in the final candidate list. Attendees were asked to vote on their top three interventions from the final candidate list. Results: There were 15 barriers and one enabler to ARO admission screening, mapped to 43 unique interventions. Of these, 16 interventions addressed more than one barrier/enabler, while 27 interventions only addressed a single barrier. Fifty-nine respondents completed the survey. Most respondents (63%) were IPC staff, 20% were nurses, and 17% were other HCWs (including IPC physicians). Nine interventions met criteria to include in the candidate list, 26 were excluded, and 8 interventions did not reach consensus in the survey and were discussed. There were 32 attendees at the consensus meeting (53% IPC staff and physicians, 34% clinical staff, 13% other provincial teams). Three interventions were selected: 1) creating a nursing task to complete the tool in the CIS when an admission order is signed, 2) add a banner on the CIS Storyboard when the tool is not complete, and 3) develop a best practice guideline for frontline staff on ARO admission screening. Conclusions: The survey and consensus meeting were efficient methods to determine a prioritized list of interventions, which will be implemented and evaluated, to improve ARO admission screening in Alberta.

Background: Universal decolonization using chlorhexidine gluconate (CHG) foaming soap in a hospital system has been shown to reduce healthcare-associated infections (HAIs) and colonization by multidrug-resistant organisms. Limited data exist on optimal strategies to improve compliance, and the impact of improved compliance on HAI rates. This study evaluates the effect of increasing CHG compliance on MRSA HAI rates. Methods: In 2022, our acute care VA hospital started universal CHG bathing treatment, by requiring a daily CHG bath for all patients in intensive care units and medical/surgical floors, unless contraindicated. Despite this, compliance was below goal. We performed root cause analyses to identify factors contributing to poor compliance, and then initiated a bundled intervention, including nursing staff education on the benefits of CHG bathing to reduce HAIs, how to reframe discussions with patients about refusals, removal of one alternative soap product from the inventory, and moving the CHG bathing product in clean supply rooms to be in proximity with other patient hygiene products for easier access. We evaluated the utilization of CHG bathing products through inventory data on utilization of 4 fluid ounce bottles of 4.0% weight/volume CHG solution, documentation of at least one CHG bath in the electronic medical record (EMR) per unique hospitalization, and HAI rates per National Healthcare Safety Network (NHSN) definitions for methicillin resistant Staphylococcus aureus (MRSA), before (08/2023-02/2024) and after (03/2024-12/2024) implementation of the bundle. Results: Identified barriers to CHG adherence included use of less effective alternative soap agents, perceptions of patient skin irritation from CHG, difficulty integrating CHG into existing workflows, and lack of understanding of the benefits of CHG bathing. After bundled interventions, inventory usage CHG bottles increased from 170 to 270 bottles per 1,000 bed days of care (BDOC) (p Conclusion: An intervention of staff education, removal of an alternative soap product, and improving access to CHG bathing products in supply rooms, resulted in improved CHG bathing adherence, and was associated with a reduction in MRSA HAIs in an acute care VA hospital. Interestingly, the decrease in MRSA HAIs was achieved despite an absence of complete adherence. Further data on additional strategies to improve compliance and strategies to improve healthcare worker documentation should be explored.

Background: The selection of agent for antimicrobial prophylaxis for urological procedures is guided by the results of urine cultures taken prior to the day of surgery, which can lead to variability. National society guidance recommends single-dose antimicrobial prophylaxis immediately before urologic surgery; however, significant heterogeneity remains among practicing urologists with regards to pre-treating (or post-treating) bacteriuria identified on preoperative urine culture as well as choice of antimicrobial administered. As part of an institutional quality improvement initiative, we endeavored to optimize antimicrobial selection and duration of therapy through the use of a dedicated preoperative urine culture paired with recommendations. Method: This was a single-center, prospective study of urological surgeries. A dedicated preoperative urine culture was created in partnership with our institution’s microbiology lab and antimicrobial stewardship program intended solely for the selection of preoperative prophylaxis. Antibiotic stewardship program members reviewed these urine cultures and provided recommendations to urologic surgeons. Primary outcome was postoperative infectious complication within 90 days, with sub-analyses performed for stone and prosthetic cases, which carry higher infectious complication risks. Result: The preoperative urine culture was ordered prior to 381 urology cases from 9/27/23-4/15/24. There were 41 (10.8%) infectious postoperative complications. 64/381 (16.8%) patients received pretreatment for asymptomatic bacteriuria at the surgeon’s discretion, deviating from protocol recommendations for single-dose prophylaxis. Similarly, 44/381 (11.5%) patients received postoperative antimicrobials off-protocol per surgeon discretion. There was no statistically significant difference in infectious postoperative complication rates among patients who received pretreatment (15.6%, n=10/64) versus those who did not (9.8%, n=31/317 [p=0.18]), nor in those who received postoperative antimicrobials (13.6% (n=6/44) versus not (10.4%, n=35/337 [p=0.44]). Subgroup analyses of patients with nephrolithiasis or prosthetic material showed no benefit with supplemental antimicrobials. There were 294 total days of therapy in cases with guidance-based prophylaxis (n=294), and 611 days for pre- and/or post-treated cases (n=87), representing an excess of 524 days of antimicrobial therapy. Conclusion: We implemented a specific antimicrobial stewardship initiative linking a urine culture ordering process to succinct evidence-based advice. Deviation from advice did not result in improved outcomes but did result in excess antimicrobial days. Subgroup analysis also suggested single-dose prophylaxis is appropriate for patients considered higher risk for infectious complications. These findings support the recommendation from the American Urological Association that a single dose of antimicrobial prophylaxis is sufficient for the majority of urologic cases and demonstrate a multidisciplinary approach to ability to safely implement such practice.