Background: Hand hygiene is the most crucial practice for reducing the transmission of infections in healthcare settings. Despite substantial data highlighting its importance, healthcare institutions frequently struggle to maintain high hand hygiene compliance rates among healthcare workers (HCWs). Low HCW hand hygiene compliance can lead to an increase in healthcare-associated infections, longer hospital stays, antimicrobial resistance, and higher healthcare costs. Low compliance can also have regulatory and reimbursement implications for healthcare systems. This highlights the urgent need for innovative interventions focused on improving HCW hand hygiene compliance. Methods: We piloted a novel program at Brown University Health (BUH) that enabled patients and visitors to audit HCW hand hygiene using an online interface. This trial was implemented in an iterative fashion in 1 outpatient clinic and 5 inpatient units over 5 months (Figure 1). A poster with program information and a QR code linked to the audit form was placed in each room and/or handed to patients/visitors. Patients/visitors were instructed to scan the QR code with their phones to access the audit form, which included three questions about their location (inpatient/outpatient), if HCWs performed hand hygiene (yes/no), and if they would feel comfortable asking staff to perform hand hygiene (yes/no). The form was available in English, Spanish, and Portuguese. Responses were recorded securely and anonymously in the online platform and monitored by Infection Control. Additionally, HCWs on these units received a survey to provide feedback on this program. Results: Patients and visitors recorded 98 hand hygiene audits of staff during the program trial: 72 from the outpatient clinic and 26 from the inpatient units (Table 1). HCW hand hygiene compliance observed by patients/visitors was 92% in both inpatient and outpatient settings, resulting in an overall compliance rate of 92% during the pilot program. Figure 1 shows HCW hand hygiene compliance rates as measured by trained BUH staff in the pilot units and clinic during 2024 in relation to the implementation of this program. We found that after the start of education and implementation of the patient/visitor hand hygiene auditing program in these units, compliance generally increased and remained above pre-intervention levels. Conclusions: This pilot program demonstrates the feasibility and potential effectiveness of engaging patients and visitors in hand hygiene interventions. The results of this pilot suggest that this novel approach warrants further investigation and broader implementation as part of larger efforts improve HCW hand hygiene compliance and reduce healthcare-associated infections.

Background: Hospitals have been recognized as major drivers of the deleterious environmental impacts of human industry. Intravenous (IV) therapy and its associated preparation and administration materials account for a large component of the plastic waste produced by hospitals. Switch therapy refers to transitioning antimicrobials from the IV to the enteral (PO) route. Despite this being a well-established practice, it has not been studied extensively in the context of reducing hospital-generated plastic waste. This study investigated the waste which could be avoided through optimization of IV to PO switch therapy. Method: A retrospective cohort study was performed at a large academic center in a metropolitan area. We included all adult patients receiving an IV antimicrobial with a highly bioavailable PO equivalent between October 2023 and September 2024. For a randomly selected subset of each agent we determined the total number of days during which patients would have been eligible for PO conversion based on our institution’s policy. This was used to determine the mean potential IV days of therapy (DOT) saved for each agent. The mean IV DOT saved were then extrapolated to the total number of patients receiving the corresponding antimicrobial agent over the course of the year to calculate a final estimated annual IV DOT which could be saved through optimized IV to PO switch therapy. A carbon emissions estimation tool was then used to estimate the carbon dioxide equivalents of the solid waste generated from the IV DOT saved. Result: A total of 15,037 DOT of IV antimicrobials with a highly bioavailable PO alternative were administered over the course of a year, of which an estimated 9,694 (64%) IV DOT could have been saved had appropriate switch therapy been implemented (Figure). This amounts to 2,049 kilograms of solid waste, or 0.353 metric tons of CO2 equivalents, generated through unnecessary administration of IV antimicrobials. This is equivalent to 904 miles driven, 40 gallons of gasoline consumed, 389 pounds of coal burned, or the energy required to maintain 23,392 fully depleted phone batteries at full charge throughout one day. Conclusion: Optimizing the implementation of IV to PO antimicrobial therapy can be an effective way of decreasing a hospital’s impact on the environment through reduction of solid waste generation. Future work should prioritize implementing life cycle assessments to broaden our understanding of how the use and production of IV medications impact the environment.

Background: Data in adults and older children demonstrate repeat blood cultures (BlCx) are not always necessary. Indications for repeat BlCx include Staphylococcus aureus or yeast in the initial blood culture, or the presence of a central venous catheter (CVC). Blood collection in premature babies can be challenging and there are little data regarding when repeat BlCxs are necessary after an initial positive. The goal of this study is to determine risk factors for persistent bloodstream infection (BSI) to determine when unnecessary blood cultures can be avoided. Methods: The Yale New Haven Children’s Hospital NNICU is a 68-bed level 4 unit. Babies in the NNICU with a positive blood culture from 8/1/16 to 12/31/21 were included. Persistent BSI was defined as a repeat positive BlCx with the same organism >48 hrs. after the original culture. A BlCx > 7 days after the original BlCx was considered a new event. Babies who died within 48 hrs. of the initial culture were excluded. In preliminary analysis we did not distinguish between true BSI and contamination. Data were extracted from the medical record by the Yale Data Analytics Team and by manual chart review. Data were stored in excel for descriptive statistics. Additional statistical analysis in SPSS is on-going to account for multiple variables. Results: 142 babies had a positive BlCx with 122 babies alive at 48 hrs. and included in the study. These 124 babies had 139 positive BlCx growing 145 organisms. Persistent BSI occurred in 17.3% (24/139) of BlCxs. Factors associated with persistence in univariate analyses included the presence of a CVC and recovery of S. aureus. (Table 1) No babies with either streptococcal infection or early onset sepsis had persistent BSI. (Table 1) Additional variables under evaluation in a multiple regression model to determine the probability of persistent BSI include other sources of infection, white blood cell count at the time of BlCx, congenital heart disease, immunosuppressive agents such as steroids and whether empiric antibiotic therapy was appropriate. We will also define probable contaminants and repeat the analyses with and without these BSI episodes. Conclusions: Preliminary analysis shows that neonates have similar risk factors for persistent BSI as adults including the presence of a CVC and the recovery of S. aureus that require repeat BlCx to confirm clearance. For babies with streptococcal infection, repeat BlCx may not be routinely required. Current work is examining additional potential risk factors in multi-variable models.

We consider a new family $(\mathcal {T}_n)_{n\geq 1}$ of aperiodic sets of Wang tiles and we describe the dynamical properties of the set $\Omega _n$ of valid configurations $\mathbb {Z}^2\to \mathcal {T}_n$. The tiles can be defined as the different instances of a square-shaped computer chip whose inputs and outputs are 3-dimensional integer vectors. The family include the Ammann aperiodic set of 16 Wang tiles and gathers the hallmarks of other small aperiodic sets of Wang tiles. Notably, the tiles satisfy additive versions of equations verified by the Kari–Culik aperiodic sets of 14 and 13 Wang tiles. Also configurations in $\Omega _n$ are the codings of a $\mathbb {Z}^2$-action on a 2-dimensional torus like the Jeandel–Rao aperiodic set of 11 Wang tiles. The family broadens the relation between quadratic integers and aperiodic tilings beyond the omnipresent golden ratio as the dynamics of $\Omega _n$ involves the positive root $\beta $ of the polynomial $x^2-nx-1$, also known as the n-th metallic mean. We show the existence of an almost one-to-one factor map $\Omega _n\to \mathbb {T}^2$ which commutes the shift action on $\Omega _n$ with horizontal and vertical translations by $\beta $ on $\mathbb {T}^2$. The factor map can be explicitly defined by the average of the top labels from the same row of tiles as in Kari and Culik examples. The proofs are based on the minimality of $\Omega _n$ (proved in a previous article) and a polygonal partition of $\mathbb {T}^2$ which we show is a Markov partition for the toral $\mathbb {Z}^2$-action. The partition and the sets of Wang tiles are symmetric which makes them, like Penrose tilings, worthy of investigation.

The Gulf of California, one of the world’s most biodiverse marine ecosystems, is also heavily exploited by fisheries. Among its fish fauna are species that, although currently underappreciated, may become commercially important in the future. Enhancing our biological knowledge of these species is crucial for monitoring population dynamics and community changes. Fish parasites offer valuable insights into host ecology, including feeding habits and population structure. In this study, we document the metazoan parasite fauna of Trichiurus nitens (Trichiuridae) from four locations in the eastern Gulf of California, Mexico. A total of 165 fish specimens were examined, revealing five parasite species identified using both morphological characteristics and molecular markers: the monogenean Octoplectanocotyla travassosi, the trematode Lecithochirium sinaloense, and three nematodes – Anisakis typica A, Skrjabinisakis brevispiculata, and Spinitectus sp. Among these, L. sinaloense was the most prevalent. Although parasite species richness was similar between small and large fish, overall parasite abundance was higher in larger specimens. Moreover, parasite assemblages did not vary significantly across the study locations. These findings suggest that T. nitens exhibits a specialized feeding strategy, relying on a narrow range of prey throughout its life, and that the oceanographic variability does not limit fish movement in the region. Future studies encompassing a broader geographical scale, additional fish size classes, and different climatic seasons are needed to further elucidate the ecological role of this species. This work provides novel insights into the host-parasite dynamics of T. nitens and establishes a valuable baseline for ecosystem monitoring under global change scenarios.

Background: Elderly Chinese residents who live in independent living facilities are a fast-growing but under-researched population. For instance, there is a lack of research regarding the various forms of social support that Chinese residents need and the barriers to receiving social support that impact health outcomes for Chinese residents. In addition, COVID-19 adds another layer of stress to Chinese people with increased social stigma. This study aims to investigate the experiences of elderly Chinese residents in an independent living facility and the existing social support gaps. Method: 16 residents from one independent living facility were recruited. Semi-structured interviews were conducted to understand their social support needs and the gaps they experienced. Interviews were conducted in Chinese with an interviewer fluent in Chinese and English. We analyzed the data using thematic analysis based on the stress, coping, and social support gaps frameworks, which resulted in twenty-seven codes, eight subthemes, and three major themes. Results: The three main themes include: (1) Stressors based on experiences and intercultural communication challenges between healthcare providers, facility staff, and residents. Most residents are aware of their aging and risk of death through experienced or observed adverse events, including stigma and events associated with COVID-19. Communicational, cultural, and instrumental challenges during the coping and help-seeking process intensify chronic stressors in the residents’ daily lives. (2) Social support received by the residents that helps with their coping. Residents receive some level of emotional and instrumental support, with children’s support being the most complete and concrete source of support. Peer support and facility support form layers of protection for residents to maintain their health. (3) Social support gaps between residents’ needs and their received social support and associated psychological symptoms. Many residents experience helplessness and dependence on their children with their current social support experience. Passiveness in help-seeking when facing stressors is also observed. Implications: Independent living facilities with Chinese residents must ensure that their providers’ communication is culturally responsive. In addition, facilities should also prioritize communicating with family members to provide social support to Chinese residents to cope with challenges in their lives and improve their physical and mental health.

Background: Carbapenem use is a primary target of antimicrobial stewardship programs with attempts made to limit usage to patients with suspected or documented multidrug resistant Gram-negative infections. Antimicrobial use (AU) data and the standardized antimicrobial administration ratio (SAAR) are metrics for comparing observed to predicted days of antimicrobial therapy and are increasingly used by stewardship programs to assess use within their institutions. However, the SAAR does not account for individual drug class or resistance rates within an institution, limiting the ability to assess appropriateness and whether a high or low SAAR requires action. To try to assess carbapenem use as a function of resistance within hospitals in Michigan, we developed a novel measure utilizing National Healthcare Safety Network (NHSN) AU and Antimicrobial Resistance (AR) data. Methods: Included hospitals had reported both AU and AR data for the calendar year of 2023. To assess the “resistance burden” requiring carbapenem use at an institution, three antimicrobial resistance phenotypes from the NHSN AR data were chosen as a surrogate; extended-spectrum cephalosporin resistant (ESC) E.coli, ESC Klebsiella spp., and resistant Pseudomonas aeruginosa, which was defined as any isolate intermediate or resistant to cefepime, ceftazidime, or piperacillin/tazobactam. The resistance rates for these three phenotypes were combined to create a weighted antibiogram for total resistance burden requiring carbapenem usage at an institution. AU data for carbapenem use per 1,000 days present for each institution was then employed to normalize carbapenem use (numerator) to resistance burden (denominator at each institution), measured as carbapenem use per unit of resistance. The median value for included hospitals was then calculated, and finally, institutional use relative to this median was reported. Results: Twenty-one hospitals, ranging from 6 to 1,011 beds, met inclusion criteria. There were 18 acute care and 3 critical access hospitals; 19 (90.4%) were part of a health system. When normalized to the median value, adjusted carbapenem use per unit of resistance within hospitals ranged from 0.214 to 4.155 (Figure 1). The highest value of adjusted carbapenem use per resistance was 19.4 times that of the lowest value. Conclusion: This novel measure of antimicrobial use attempts to correct for the burden of resistance in individual facilities. As such, when applied to hospital populations, this represents a step forward in assessing antimicrobial use appropriateness and would have public health impact related to antimicrobial stewardship efforts. Future objectives include application to additional hospitals, years of data, antimicrobial resistance phenotypes, and agents.

Background: Candida auris (C. auris) is a resistant fungal pathogen that persists in the hospital environment and poses a significant infection risk, particularly to immunocompromised patients. Early detection and infection control are vital for patient safety as C. auris may spread between patients in healthcare settings through contact with contaminated surfaces. The Centers for Disease Control and Prevention (CDC) and Texas Department of State Health Services (Texas DSHS) recommend screening high-risk patients, including those previously hospitalized abroad, in rehabilitation or long-term care facilities, or those with indwelling medical devices, mechanical ventilation, immunocompromised conditions, or colonization by other multidrug-resistant organisms. We developed a C. auris screening program based on these guidelines, local epidemiology, patient risk factors, and facility characteristics. Methods: An initial point prevalence survey was conducted to identify our high-risk patient population, but no positive screening results were found during our pilot study. However, a retrospective review of patients with clinical C. auris infection revealed 53% (8/15) had transferred into our center from other healthcare facilities. A targeted screening program of transfer patients was developed, and a needs assessment identified gaps in infection prevention practices, staff knowledge, and laboratory capabilities. Patients meeting screening criteria had composite swabs collected from axilla and groin creases, which were sent to an external lab for C. auris PCR testing. A tracking system was established for patients, results, and newly identified infections. Newly identified colonization cases received targeted infection control measures and were placed on isolation. Results: During the first four months of the screening protocol, 588 transfer patients have been screened, reflecting 5.47% of all admissions. We identified ten positive colonization cases, yielding a 1.82% positivity rate. In addition, two C. auris infections were identified. Conclusion: Overall, our C. auris colonization rates are low. This may reflect differences in patient population or screening practices. Identifying ten colonized patients through our screening protocol enabled timely isolation and targeted infection control measures, preventing possible horizontal transmission in a high-risk patient population. Ongoing monitoring and evaluation will inform our screening practices and enhance our ability to respond to outbreaks. As the prevalence of C. auris continues to grow, our screening program will continue to provide a proactive approach to managing this growing threat to our highly vulnerable patient population.

Background: The association between social determinants of health (SDOH) and healthcare-associated infections is underappreciated. We evaluated disparities in rates of candidemia associated with the social vulnerability index in Denver area census tracts. Methods: We conducted an ecologic study of the 664 census tracts within Adams, Arapahoe, Denver, Douglas, and Jefferson Counties, Colorado in 2021 and 2022. The outcome of interest was census tract rates of candidemia, with cases captured by population-based surveillance of the Centers for Disease Control and Prevention’s (CDC) Emerging Infections Program and geocoded to census tract of residence. The primary explanatory variable was the CDC and Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI) from 2022 and its four themes: socioeconomic status, household characteristics, race and ethnic minority status, and housing type and transportation. Population denominators were taken from the 2018-2022 American Community Survey, and census tract boundaries from the 2020 US Census. We used bayesian conditional autoregressive models to map smoothed rate ratios (RRs) of candidemia relative to the five-county catchment area rate and to estimate RRs and 95% credible intervals (CIs) associated with a 0.1 unit increase in SVI and each SVI theme. Analyses were conducted using SAS 9.4, RStudio 2023.06.0, and OpenBUGS 3.2.3 software. Results: Of 664 census tracts, 658 (99%) had a greater than zero population for which rates could be calculated. There were 333 candidemia cases in 5,652,254 person-years, of which 321 (96%) were geocoded and included in the analysis. Disease mapping indicated clusters of census tracts with higher than expected rates of candidemia relative to the five-county catchment area after adjusting for sex and age (Figure). For every 0.1 unit increase in census tract SVI, there was a 15% increase in the rate of candidemia (RR 1.15, 95% CI, 1.10, 1.20) after adjusting for sex and age. There were similar, modest associations with each SVI theme. Discussion: We demonstrated clustering of census tracts with higher than expected rates of candidemia and a modest association with SVI. Healthcare and public health epidemiologists should consider the contribution of SDOH to population rates of candidemia with an eye toward identifying opportunities to improve health equity.

Background: Clostridioides difficile infections (CDI) are a leading cause of health-care associated morbidity and costs. University Health Truman Medical Center is a longstanding 238-bed safety net hospital in Kansas City, MO, where there was an increase in hospital-onset (HO) CDIs in 2024. To improve our infection prevention and control measures, we sought to study these HO CDI cases. Methods: Using a retrospective cohort study design and electronic health records, we retrieved data for inpatients who were identified as having HO CDI by our department of infection prevention and control in 2024. HO CDI was defined as a positive test for toxigenic Clostridioides difficile (C. difficile) polymerase chain reaction (PCR) performed on unformed stool collected on hospital day > 3 (with preagreed intuitional criteria in place). Data included demographic and epidemiological variables, comorbidities, onset of diarrhea and timing of stool collection, length of stay (LOS) and exposures (within prior 6 months) to hospitalization, surgery, and/or medications including laxatives, proton-pump inhibitors, immunosuppressants and antimicrobials. Results: In 2024 there were 20 HO CDI cases (versus 9 in 2023) with consequent increase in the CDI rate per 10,000 patient days and the standardized infection ratio. The characteristics of the CDI cases (percentage; mean ± standard deviation) were as follows. Most cases were females 60%. The mean age was 61 ± 18 years and BMI 28 ± 11 kg/m2. Recent hospitalization was common; 50% of cases had been hospitalized within 28 days and 70% within 6 months of their positive C difficile test. All cases had one or more comorbid conditions while one patient (5%) had past history of CDI. The median LOS was 18 days with frequent room changes and 35% of cases had an intensive care unit exposure. All had received systemic antibiotics either singly or in combination and the most commonly used agents included cephalosporins (90%) and penicillins with beta-lactamase inhibitor (35%). Laxative use was common (65%) as were history of surgery (55%) and intravenous contrast exposure (50%). Most cases (70%) were treated with oral vancomycin with three cases receiving a taper/prophylaxis, while five cases received fidaxomicin; there was one case of recurrence. Conclusions: Recent hospitalization and laxative use were high among HO CDI cases in a safety net hospital, raising concern for potential over-diagnosis. Switching to a two-step C difficile stool testing algorithm (PCR+ toxin enzyme immunoassay), though more costly, would be a useful mitigation strategy.

Background: Clinicians have variable prescribing practices for treating urinary tract infections (UTI), resulting in broader and longer treatment durations than necessary. In March 2023, guidelines for UTI treatment were developed and disseminated across our hospital system. Methods: We evaluated inpatients at Emory University Hospital (EUH) who received antibiotics with an indication of UTI between November 2022 and March 2024 to investigate implementation effect on treatment duration and choice. We characterized days of therapy (DOT) by performing interrupted time series analysis, adjusting for demographic and clinical variables. Additionally, we looked at percent use of guideline concordant antibiotics chosen before and after implementation. Results: A total of 978 cases of UTIs were evaluated pre-guideline implementation among 621 (63.5%) females with 490 (50.1%) Black patients. A total of 1420 cases of UTIs were evaluated post-guideline implementation among 843 (59.4%) females with 693 (48.8%) Black patients. With inpatient UTI DOT, following implementation there was an increase by 31.5 DOT/month with a sustained increase by 6.25 DOT/month with no statistically significant change. Total UTI DOT (including outpatient) showed a sustained decrease by 21.1 DOT/month with no overall statistical significance. With inpatient UTI guideline concordance, following implementation there was an increase by 2.5% per month with a sustained increase by 0.7% per month with no statistically significant change. Total UTI guideline concordance (including outpatient) showed a sustained increase by 1.4% per month with no overall statistical significance. Conclusion: Guideline implementation for UTI treatment did not lead to statically significant change in DOT or guideline concordant prescribing at EUH.

Background: A comprehensive understanding of antimicrobial prescribing practices, requires antimicrobial stewardship (AMS) clinicians to assess both the quantity and quality of antimicrobial prescribing. In Australia, two national programs collect and analyse such data in the hospital setting; the National Antimicrobial Utilisation Surveillance Program (NAUSP) a continuous, volume-based surveillance program that monitors antimicrobial usage trends; and the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) a standardised auditing program that assesses antimicrobial prescribing appropriateness. This study aims to analyse the 2023 NAUSP and Hospital NAPS data to compare the volume and appropriateness of inpatient antimicrobial use in Australian hospitals. Methods: Data were extracted from hospitals that participated in both programs in 2023, including systemically administered antimicrobials for adult patients. NAUSP data were aggregated and acute inpatient usage rates relative to patient activity were calculated as Defined Daily Doses (DDD) per 1,000 Occupied Bed Days (OBD) for individual antimicrobials.

Hospital NAPS data on appropriateness of prescribing, as assessed by local auditors as a point prevalence survey and using a standardised assessment matrix, were aggregated and calculated for each antimicrobial. Antimicrobials with high-volume use (NAUSP data), high rates of antimicrobial prescribing (NAPS data), or classified as medium to high risk for antimicrobial resistance potential according to the World Health Organization AWaRe classifications were further investigated. Results: There were 192 acute care hospitals that contributed in 2023 to both NAUSP (representing 12, 619, 253 OBDs) and Hospital NAPS (representing 21,017 antimicrobial prescriptions). Figure 1 summarizes the aggregate usage rates and appropriateness for antimicrobials of interest. Antimicrobials with the highest usage rates, including amoxicillin-clavulanic acid and cefazolin (92.2 and 78.8 DDD/1,000 OBD respectively), had moderate levels of appropriateness (67.8% and 69.9% respectively). Similar ‘Access‘ antimicrobials such as doxycycline, amoxicillin and metronidazole, which tend to be unrestricted in hospital formularies, had moderate levels of appropriateness. Cefalexin had the lowest rate of appropriateness (52.2%). In comparison, ‘Watch‘ antimicrobials, including meropenem and vancomycin, which tend to be restricted, had lower usage rates (14.3 and 19.8 DDDs/1,000 OBD respectively) but higher rates of appropriateness (83.5%, 82.8% respectively). Conclusion: This analysis highlights the importance of assessing and analyzing antimicrobial quantity and quality concurrently, providing a holistic view of prescribing practices. Furthermore, AMS efforts should include all antimicrobials, regardless of restriction category, as commonly used, unrestricted antimicrobials may have substantial rates of inappropriate prescribing.

Background: The 2019 American Urological Association (AUA) best practice statement for Urologic Procedures and Antimicrobial Prophylaxis recommends single-dose peri-operative antimicrobial prophylaxis (e.g. cefazolin or trimethoprim/sulfamethoxazole) not to continue past closure of the incision for Class I and II genitourinary (GU) procedures even in the presence of asymptomatic bacteriuria (ASB). Class I and II GU procedures encompass the majority of urologic procedures which are clean procedures in low risk patients and clean-contaminated procedures, respectively. The objective of this study is to assess current urologic antimicrobial prophylaxis practices at a large academic medical center. Methods: This retrospective observational study included adults who underwent a urologic procedure from September-October 2024 to assess AUA guideline adherence. Patients with a history of renal transplant, documented concern for symptoms consistent with urinary tract infection prior to the procedure, or receiving antibiotics for another condition were excluded. Both inpatient and outpatient preprocedural, intra-operative and postprocedural antibiotics were evaluated. Pre-procedural urine cultures results, attending of record, and type of procedure were correlated with prophylaxis practices using a one way ANOVA. Results: Of the 80 patients reviewed 41.3% received only single dose pre-operative prophylaxis and 57.5% received Discussion:

Nearly half of patients who underwent urologic procedures had a prophylaxis duration of < 2 4 hours in concordance with the AUA best practice recommendations. Opportunities exist for optimizing agent selection education. No difference in length of prophylaxis was found to correlate between different procedures performed. The presence of pre-operative ASB and ordering attending were found to correlate with an increased duration of prophylaxis. A future institutional practice guideline and order set for urologic procedure antimicrobial prophylaxis may be necessary to optimize agent selection and duration for these GU procedures.

Background: A Quality Improvement (QI) initiative to reduce invasive Staphylococcus aureus (SA) infections in a level IV neonatal intensive care unit (NICU) successfully eliminated Methicillin-resistant (MRSA) but not Methicillin-susceptible (MSSA) infections. A combination of SA whole genome sequencing (WGS) and environmental culturing helped to better understand the epidemiology of MSSA colonization and infection in the NICU and drive new infection prevention interventions. Methods: Environmental surveillance of high-touchpoint surfaces for SA was performed using Dey and Engley neutralizing agar. Selected isolates were confirmed as SA using Columbia Sheep’s Blood agar and Staphaurex testing. Statistical analyses examined correlations between monthly effective cleaning, hand hygiene compliance, and colonization rates. To better understand MSSA spread in the NICU, WGS was performed on a convenience sample of 42 MSSA isolates, sampled one month before and after an invasive MSSA infection. Data extracted from electronic health records were used for retrospective room tracing of colonized patients with related isolates to determine modes of transmission. Results: WGS analysis MSSA isolates revealed four MSSA strains from 29 patients suggesting within unit transmission, while 13 patients were colonized with unique MSSA isolates suggesting external sources. Retrospective room tracing of colonized patients identified three transmission patterns: subsequent room occupant transmission, intra-pod spread, and inter-pod transmission without patient transfer, with evidence that these strains were endemic within the unit for at least 3-12 months. Statistical analyses showed no significant correlation between environmental cleaning or hand hygiene compliance and colonization rates. Conclusions: Persistent MSSA colonization and invasive infections in the NICU result from both within-unit transmission and the introduction of unique isolates. These findings are being used to inform the development of new interventions, including updated below-the-elbow hand hygiene protocols, revised environmental cleaning plans, nurse-parent communication training, and a virtual reality hand hygiene training program for parents and staff. WGS of pathogenic organisms is a useful tool to drive QI initiatives aimed at reducing hospital-acquired infections.

Introduction: The estimated annual incidence of tuberculosis (TB)in the United States amongst health care personnel (HCP) is low at 2/100,000 persons. Current TB post exposure testing practices may result in many HCP being contacted and tested, with very low yield, thus leading to increased health care resource utilization and HCP anxiety. Based on CDC criteria, Mayo Clinic, Rochester is a medium risk facility. Given that the only transmission we have seen in the last decade is from smear positive, symptomatic patients, we present an alternative, risk-based approach to defining exposure risk to guide followup testing for health care personnel exposed to TB patients. Our goal was to account for the most common exposure follow up (EFU) scenarios and not the rarest situations, which would require case by case discussion. We present a novel risk stratification definition for EFU testing at Mayo Clinic, Rochester and present 12 months’ worth data pre and post initiative. Methods: Prior to July 2023, case exposure definition for screening was broad without clarity on duration of exposure or risk for acquisition of the disease. After the new definition was proposed in collaboration with Infection prevention and control (IPAC), Occupational safety and health, and Minnesota department of health, each case was reviewed to determine appropriateness of HCP exposure testing Results: In the time frame from July 2022 through June 2023, total of 5 EFUs were conducted, and 70 healthcare personnel were exposed (14 per EFU), and none developed TB infection [MS1] After implementation of new protocol, during July 2023 through June 2024, there were 11 EFUs, 102 healthcare personnel were identified as exposed (9 per EFU), and none developed TB. Of note, the low number of exposure investigations prior to July 2023 coincides with the universal [MS2] masking policy related to the COVID-19 pandemic. Conclusion: Existing public heath guidelines do not establish minimum exposure time warranting follow up testing for tuberculosis amongst HCP. However, not all cases need extensive case management as this may lead to excessive costs and resources for testing, conducting EFUs and anxiety amongst HCP. With our proposed exposure risk stratification, we aim to not only reduce resources and time needed to conduct EFUs, but also decrease incorrectly identified HCP to assure the correct ones are being tested. We will continue to audit and review our data at regular intervals with continued feedback and discussion with stakeholders to adopt a more data driven approach to TB exposure followup.

Voluntary assisted dying (VAD) is an end-of-life care option available to eligible Australians living with a terminal condition, though people living with dementia are typically ineligible to choose VAD as part of their end-of-life care. In order to develop equitable research-informed policy and practice, it is crucial to include the perspectives of all key stakeholders, including living experience experts whose voices are currently excluded from Australian VAD research. This study aims to capture the perspectives of people living with dementia by exploring their VAD-related needs and preferences. The study is grounded in a critical and phenomenological conceptual framework that prioritizes inclusive research design. Thirty-six people living with dementia in Australia self-selected to participate in an online survey. It found that the vast majority of participants wanted the option to access VAD themselves, and most wanted provisions for accessing VAD through advance care directives. Through open text responses, the participants expressed many concerns about potential end-of-life suffering and loss of dignity, with their VAD preferences often aligned with their wish to maintain autonomy and human rights. This is the first known Australian study to explore VAD from the perspective of people living with dementia, providing critical insights into their experiences as stakeholders in a highly contested policy and practice environment that is dominated by medico-legal voices. Centring on people living with dementia challenges misconceptions about their capacity to contribute to VAD research, demonstrating their importance as living experience experts and key stakeholders with clear needs and preferences for their end-of-life care.

Background: Patients with cirrhosis often experience coagulopathy, which can result in profound bleeding at intravenous insertion sites. This makes maintaining dry, intact central venous catheter (CVC) dressings particularly challenging. At our 2,247-bed acute care tertiary referral hospital, the Medical-Surgical Intensive Care Unit (MSICU) specializes in hepatic care.

Upon completing a root cause analysis of our elevated central line associated blood stream infections (CLABSIs), we found patients with coagulopathy had poor CVC dressing adherence. Our goal was to reduce CLABSIs by improving dressing integrity through innovative strategies aimed at mitigation of bleeding and enhanced adhesion. Method: In November 2022 a review was completed of hemostatic and adhesion products to address bleeding at CVC insertion sites and improve dressing adherence to skin. In December 2022 we developed a tiered intervention program using three products tailored to the severity of bleeding at CVC insertion sites. We then selected an adhesive product to bond the perimeter of the dressing to the skin. We disseminated education to the nursing team on product use according to patient CVC dressing condition and manufacturer instructions for use. The tiered intervention program was evaluated by comparing pre-intervention (January 2021 to November 2022) CLABSI rates and standardized infection ratios (SIRs) to post-intervention (December 2022 to October 2024) outcomes. Data was obtained from the National Healthcare Safety Network (NHSN), and analysis was completed using the NHSN statistics calculator. Result: Following implementation of the tiered intervention program, the CLABSI rate decreased from 1.67 to 0.62, a 62.9 percent decrease. The CLABSI SIR decreased from 1.481 to 0.553, a 62.7 percent decrease. The CLABSI SIR reduction was statistically significant (p-value of 0.0318; one tailed Z-test). Conclusion: Patients with coagulopathy issues pose unique challenges in infection prevention. Their abnormal clotting factors increase the risk of bleeding, making it difficult to maintain an intact and occlusive CVC dressing. Hemostatic and adhesive products are effective strategies for maintaining CVC dressing integrity and facilitating CLABSI reduction.

Introduction: Enterococci are the third most common healthcare-associated pathogen, with 30% of isolates resistant to vancomycin (VRE). Resistance is often conferred by the vanA gene cluster on transposon Tn1546 and is frequently plasmid-borne. The suspected role of person-to-person transmission prompted the recommendation for VRE isolation precautions in 1995. However, quasi-experimental studies in hospitals discontinuing these precautions found no significant increases in VRE infections or bacterial clone spread using short-read whole genome sequencing (WGS). We used long-read WGS to analyze vanA plasmid transmission dynamics after discontinuing isolation precautions for VRE at Stanford University Hospital. Methods: This study was conducted at Stanford University Hospital, an 800-bed quaternary referral and transplant center. Routine contact precautions for VRE were discontinued on October 1, 2021. Blood culture Enterococcus faecalis and E. faecium isolates collected during 2021 (prior to and following discontinuation) were included, along with additional isolates retrieved from January–October 2023. Bacterial whole genome sequencing with long-read nanopore technology was performed. Custom analyses were performed on the assembled genomes. Patient data were collected retrospectively. Results: We retrieved 105 blood culture isolates (36.2%) from the isolation period (January–October 2021) and 185 isolates (63.8%) from the no isolation period (October–December 2021, January–October 2023), representing 202 unique patients. Patient characteristics and microbiological findings are shown in Table 1. Only 4.3% (7/171) of E. faecalis and 70.5% (84/119) of E. faecium isolates were vancomycin-resistant. Long-read WGS revealed no clustering between the isolation and no isolation periods. (Figure 1A and B); however, a dominant E. faecium ST117 cluster was seen, while E. faecalis showed greater diversity (Figure 1C). There were only four pairs of putative transmissions Conclusion: The discontinuation of contact isolation precautions at Stanford Hospital did not result in an increase in genetically related Enterococci or genetically related vanA plasmids among patients with Enterococcal bacteremia.

Background: The Agency for Healthcare Research and Quality Safety Program for MRSA Prevention Surgical Services cohort aimed to reduce surgical site infections (SSIs) and prevent methicillin-resistant Staphylococcus aureus (MRSA) in teams performing surgeries at high risk for infection with and high morbidity due to MRSA (cardiac, knee or hip replacement, and spinal fusion) using evidence-based infection prevention interventions and the Comprehensive Unit-based Safety Program (CUSP) framework. We report process and outcome measures associated with program participation. Methods: The Surgical Services Safety Program for MRSA Prevention was implemented from January 2023 to June 2024. The aim was to increase teamwork and collaboration, reinforce safety culture, implement evidence-based infection prevention practices, and decrease SSIs and MRSA. The project team provided 22 live webinars, supporting materials, and other tools to assist surgical teams (Table 1). Teams were also assigned an implementation advisor who provided support through monthly coaching calls.

Teams submitted baseline and endline information on patient safety culture and on infrastructure at the team- and hospital-level, as well as monthly data regarding process measures and SSIs. Teams submitted SSI data from 12 months prior to the start of the program and for 18 months after program implementation. Changes were assessed using pre-post comparisons with Chi-squared test and linear mixed effect models with random intercept. Results: 104 surgical teams (18 cardiac, 19 neurosurgical spinal fusion, 16 orthopedic spinal fusion, 51 knee/hip replacement) from 63 hospitals completed the program. Significant improvements in team-based process measures of surgical team infrastructure (Figure 1) and in teams’ reporting that patients received evidence-based practices (Figure 2) were observed across several areas from baseline to endline, including preoperative decolonization, appropriate antibiotic prophylaxis, and intraoperative infection prevention procedures. While SSI rates did not significantly change, the observed 23% decrease in overall deep or organ space SSI rates approached statistical significance (95% CI -0.46, 0.01) (Table 2 and Table 3). Conclusions: The AHRQ Safety Program for MRSA Prevention supported implementation of evidence-based infection prevention practices to prevent MRSA and SSIs in high-risk surgeries. Participating teams showed improvements in team-based process measures and observed a reduction in deep or organ space SSI rates.

Introduction: Athletes in contact sports have a higher rate of Staphylococcus aureus nasal carriage than the general population, leading to an increased risk of skin and soft tissue infections (SSTIs). These infections can have a significant impact on individual players and teams. This study aimed to assess the effectiveness of adding a nasal decolonization protocol in reducing S. aureus colonization among a Division I (D1) college football team to chlorhexidine gluconate body wash. Methods: A total of 113 athletes were screened for S. aureus nasal carriage at two time points during intensive summer training. During the first screening, athletes were universally prescribed intranasal mupirocin twice daily using clean Q-tips for five consecutive days. Players were also educated on proper hygiene and adherence to the decolonization protocol. Four weeks later, all players were screened again for S. aureus nasal carriage. Protocol success was defined as either detection of Staph aureus in the first round of screening but not in the second (elimination) or a persistently negative result (lack of acquisition). Protocol failure was defined as either the isolation of the same organism in the first and second rounds (lack of elimination) or a positive second-round culture following a negative first-round culture (acquisition). Select S. aureus isolates were submitted for multilocus sequence typing (MLST). Results: At the initial screening, 2 players (1.8%) were colonized with methicillin-resistant Staphylococcus aureus (MRSA), 23 players (20.4%) with methicillin-susceptible Staphylococcus aureus (MSSA), and 4 players (3.5%) with both MRSA and MSSA. After decolonization, follow-up screening identified 0 players with MRSA and 12 players (10.6%) with MSSA, representing a 58.6% reduction in overall S. aureus nasal carriage. Based on study definitions, the decolonization protocol was successful in 101 (89%) players (Figure 1).

MLST was performed on 11 of the 27 initial MSSA-positive isolates and 6 of the 12 second-round MSSA-positive isolates. Based on limited molecular typing data, at least 1 player may have acquired MSSA from another team member within the athletic environment. Discussion: Our findings suggest that implementing a nasal decolonization protocol in a D1 college football team is feasible and effective, resulting in a significant reduction of S. aureus nasal carriage. While initial screening effectively identified carriers, a small subset of athletes acquired MSSA colonization, indicating potential re-exposure or incomplete protocol adherence. Further research should explore decolonization adherence strategies and expand decolonization efforts across contact sports programs to reduce S. aureus-related SSTIs among athletes.