Background: Central line-associated bloodstream infections (CLABSIs) remain an important, preventable healthcare-associated infection. Prolonged catheterization is a major risk factor, and avoidance and prompt removal of unnecessary central lines (CL), including peripherally inserted central catheter (PICC), can reduce CLABSIs. We aimed to evaluate potential opportunities to reduce PICC utilization and associated harm. Methods: This was a cross-sectional observational study of hospitalized patients with PICCs from June 1 to June 30, 2024 at an 877-bed tertiary care hospital in Detroit. CL indications using evidence-based and institutional guidelines, duration of catheterization, and complications of line were evaluated. Results: 145 patients had PICCs (Table 1). Of these, 114 (78.6%) were placed at bedside in the general practice unit, 31 (21.3%) in the ICU and the majority (57.5%) were double lumen. Common indications included total parental nutrition (TPN) (59, 40.7%) and outpatient parenteral antimicrobial therapy (OPAT) (58, 40%). 22 (15%) patients did not have an established indication for PICC placement. Among patients receiving PICC for TPN, 9 (15%) did not meet criteria, and 9 (15%) were on TPN for < 5 days. Amongst those discharged on OPAT, 14 (24%) had opportunity for oral sequential therapy; 11 (19%) patients only received treatment for < 28 days. Although 26 (18%) patients had CL placed for difficult access, half of them had a concurrent or subsequent PIV or midline. Median duration of CL was 25 days (range: 2-499), and a third had CL placed for < 1 4 days. Overall, 22 (15.7%) patients were identified to not meet any indication for PICC and of those who received double or triple lumen catheter, 62 (73%) qualified for single lumen catheter only. Complications occurred in 13 (9%) patients, including CLABSI (6, 4.1%) and thrombotic events (4, 3%). Eight (5.5%) patients had line-related readmission. Conclusion: Upon review, PICC lines were commonly overutilized, and contributed to increased CLABSI rates. Several opportunities to reduce CLABSIs were identified, including reinforcement of appropriate CL indications, increase midline utilization for shorter duration of therapy and difficult access. These findings also encourage use of oral sequential therapy instead of OPAT, and placement of single lumen catheters where indicated.

Conventional-politics approaches, emphasizing party ideology, electoral dynamics, committee membership, campaign donations, and industry clout, exercise a powerful hold over assessments of public policies and their distributional effects. Emerging from pluralist and business power perspectives, such accounts see “who gets what and why” as the result of how politics and power shape policies, their implementation, and distributional outcomes. This pervades our understanding of the Paycheck Protection Program (PPP), the US government’s effort to avert mass unemployment during the COVID-19 pandemic by lending $786 billion to small businesses to keep employees on the payroll. Yet contrary to prior studies of the PPP, we find that conventional-politics factors were strikingly uncorrelated with distributional outcomes, revealing limits to such approaches to this case. Instead, we find that an institutional politics or politics-in-time (IP-PIT) analysis better explains the program and its trajectories. IP-PIT revises the causal sequence by emphasizing how institutions and policies generate politics, distributional outcomes, and feedback loops. We engage both approaches via a mixed-methods analysis of the PPP and two new datasets. We conduct a qualitative process tracing of temporal variation in policy architectures, politics, policy revisions, and access to loans across the program’s three periods, and present quantitative analyses of loan flows across congressional districts and periods using data on the entire corpus of PPP loans. In so doing, we advance research and debate over the PPP, the dynamics and outcomes of US policy making during crises, and the American political economy in general. Ours is the first study of the PPP to conduct a mixed-methods analysis of loans across congressional districts or to use conventional and institutional approaches to address its politics, policy, and outcomes. More broadly, we document varieties of critical junctures, contribute arguments about what might shape policy or institutional innovation in those moments, and use the PPP to identify conditions under which systems are “their own grave diggers,” fueling negative-transformative rather than positive-reproductive feedback.

Background: Antibiotic tracking and reporting are core components of nursing home (NH) antibiotic stewardship programs. Nevertheless, how NHs conduct these essential activities remains poorly understood. The objectives of this study were to understand how NHs capture information on antibiotic use (AU) and characterize how AU is reported in Wisconsin NHs. Methods: The Antibiotic Tracking and Reporting Inventory (ATARI), a survey instrument designed to characterize the structure and process of antibiotic tracking and reporting in NHs was developed and piloted through a mixed methods approach. The instrument is organized into three sections: facility demographics, structure and process of AU data collection, and types of AU measures reported and methods of generation. After coding into REDCap, the ATARI instrument was distributed to Wisconsin NHs (n = 328) in partnership with the Wisconsin Department of Health Services. Descriptive statistics were utilized to summarize information regarding antibiotic data collection, AU reporting, and NH characteristics. Results: One hundred and thirty-two responses were received, of which 98 completed the instrument in its entirety for a final response rate of approximately 30%. Figure 1 details NH characteristics, including size and information system employed by responding facilities. Responding NHs reported devoting approximately 10 hours per week doing line listing activities and 18 hours per month in developing and disseminating reports (Figure 2). Paper and facility-developed Excel-based tools were used to conduct line listing activities in a majority of NHs, and 32 NHs employed more than one tool for this purpose (Figure 2). A majority, approximately 84%, of NHs reported at least one measure of antibiotic initiation although there was variation in whether facilities employed starts, courses, and treatment measures (Figure 3). Nineteen NHs utilize one or more report tools. A majority of NHs employed rate adjustment and stratification of their initiation measure by indication as well as appropriateness in their reports (Figure 3). In contrast a minority, 39%, of NHs reported a treatment duration measure (Figure 3). Conclusions: Wisconsin NHs devote a considerable amount of time to tracking and reporting of AU and employ a variety of low-tech tools for this purpose. There is considerable variability in the types of AU measures monitored in NHs with a majority focused on antibiotic initiation measures and lesser focus on measuring duration of therapy. These results suggest a need for standardization of AU measures in NHs as well as information systems that improve the efficiency of their collection and reporting.

Background: There is limited evidence to guide the diagnosis and treatment of urinary tract infections (UTIs) in men. We hypothesized that lower clinician confidence in ability to correctly diagnose or treat UTIs in men would be associated with increased antibiotic treatment duration. Methods: We surveyed clinicians’ knowledge and confidence in diagnosing and treating UTIs in outpatient men as well as their intention to prescribe a specific duration of antibiotics. We distributed the survey to outpatient primary care and emergency medicine providers, urologists, and internal medicine residents. We collected demographics on professional role (physician-attending, physician-trainee, advanced practice professionals [APPs]), specialty, and years in practice. Surveys were distributed on paper and electronically. Analysis involved t-test and ANOVA for continuous variables and Chi-squared for categorical variables as appropriate. Multiple logistic regression analyses were performed using the outcome variable of antibiotic treatment duration, categorized as appropriate (5-7 days) or inappropriate (> 7 days). Results: 186 of 363 distributed surveys were completed (51% response rate). Fifteen surveys were excluded due to the respondent specialty (e.g., dermatology, neurology, etc.), leaving 171 surveys for analysis. Of these, 60% were from trainees, 26% attendings, and 14% APPs (Figure 1). Most physicians (Figure 2) were internal medicine trained (81%), with a smaller proportion of family medicine (8%), urology (6%), and emergency medicine (5%). 14% of respondents reported an intention to treat UTIs in men for longer than 7 days (Figure 3). Lower clinician confidence in ability to correctly diagnose male UTI was associated with longer intended antibiotic treatment durations (Odds Ratio [OR] 0.42, Confidence Interval [CI] 0.19-0.91, p = 0.03). This association was independent of professional role, specialty, and years in practice. Lower clinician confidence in ability to correctly treat male UTI was not significantly associated with longer intended treatment durations (OR 0.46, CI 0.21-1.03, p = 0.06) on univariate analysis but was significantly associated when adjusted for years since graduation (OR 0.40, CI 0.17-0.96, p = 0.04). Confidence in diagnosis (Figure 4) was significantly different between professional roles, with trainees significantly less confident (median ± standard deviation = 3.1 ± 0.56) than attendings (3.7 ± 0.47, p) Conclusions: Lower confidence among clinicians in either diagnosis or treatment of UTIs in men was associated with intention to prescribe longer antibiotic courses. Future studies that address the evidence gaps in diagnosis and management of UTI in men may improve clinician confidence and thus reduce unnecessarily long durations of antibiotics.

How do the gendered patterns of foreign aid operate in the rare occurrence when refugee men are the focus of aid programs? This article uses critical narrative analysis to understand refugee men’s navigation of gendered hierarchies in the aid program Darfur United, a refugee men’s soccer team formed in eastern Chad’s refugee camps. Through juxtaposing the objectives and aims of Darfur United as a program for men with those of aid programs for refugee women and children, I argue that men must demonstrate innocuous and essentialized practices of masculinity to receive care, while ultimately serving as conduits for increased humanitarian support for refugee women and children. This analysis extends existing literature on the absence of humanitarian programs for refugee men and disrupts dominant understandings of gender and refugee men. By centering men’s own understandings of aid’s gendered patterns, it expands contemporary discussions on gender, displacement, and humanitarianism.

Background: Vancomycin-resistant Enterococcus (VRE) is a pathogen that can cause nosocomial infection leading to increased morbidity and mortality. Healthcare provider interactions have been reported to cause nosocomial infection acquisition. Here we aim to understand patient-staff interactions by mapping their interactions together with the movement of VRE colonised patients in an acute inpatient setting in a tertiary hospital for one month to create a dynamic visualisation map. Methods: Staff-patient interactions were obtained through documentation in the electronic health records (EHR). Hospital-onset VRE Hospital-Onset acquisition is defined as a positive screen/culture on or after the third day of admission. The cohort was categorised by their VRE statuses such as Hospital-onset (HO), Community-onset (CO) defined occurring before the 3rd day of admission, Infectious period (XO) and Negative (NO). XO is estimated to be the two days before a positive test HO acquisition. NO patients in this cohort eventually turn positive during their admission. A network was generated where patients and staff were represented as nodes, with edges weighted by number of interactions with the specific staff. Node colours were assigned based on VRE status. An interactive patient-staff interaction network map was developed using Python 3.12.8, using PyVis library version 0.3.2 for network visualization and Dash version 2.18.2 for web-based interactivity. Results: There are a total of 207 patients who tested positive for VRE in SGH in July 2024. 54 (26.1%) were HO. A snapshot of the map filtered for 10/07/24 to 11/07/24 can be seen in Figure 1. 14 (11.8%) were HO, 58 (48.7%) were CO, 44 (37.0%) were NO and 3 (2.5%) were XO. As seen in figure 1, there are 7 (5.9%) are in isolated singular clusters, 6 (5.0%) are in pair clusters and 3 (2.5%) are in a triple cluster. In total, the largest cluster consists of 103 (86.6%) patients. This cluster consists of HO,NO,CO and XO patients. This intermingling highlights potential routes for cross-transmission of VRE. Conclusion: The network map reveals notable intermingling of CO, HO, XO and NO contacts within the dominant cluster and suggests potential routes of transmission. This underscores the need for better understanding of transmission dynamics to allow enhancement of existing infection prevention policies to prevent this spread.

Introduction: With the expanding use of non-culture based tests (NCTs), the CDC’s National Healthcare Safety Network (NHSN) incorporated NCTs into the surveillance definition for central line-associated bloodstream infections (CLABSI) in 2016. However, there are limited data available on the impact of NCTs on CLABSI surveillance since that time. In this study, we aim to describe the test performance characteristics of a NCT which detects microbial cell-free DNA (Karius® Test [Redwood City, CA: Karius, Inc]) for bloodstream infection diagnosis and to determine the impact on CLABSI surveillance within a pediatric healthcare facility. Method: This study was performed at a 654-bed quaternary care pediatric healthcare facility in central Ohio from January through December 2024. All patients with Karius® Testing performed on or after hospital day 3 were included. Sensitivity, specificity, and positive predictive value (PPV) for Karius® Tests to diagnose bloodstream infections were determined from patients with paired blood cultures collected within 2 days of the Karius® Test. Patients with positive and negative Karius® Tests were compared using Fisher’s exact test and Wilcoxin rank sum test. Analyses were completed using Stata version 18 (College Station, TX: StataCorp LLC). Viral data were excluded from the analysis. Single growth of common commensal organisms on blood culture were treated as contaminants. Result: Eighty-six patients with a total of 91 Karius® Test results were included in the analysis (Table; Figure). Patients with a positive Karius® Test were younger and more likely to have a positive blood culture (p Conclusion: In our cohort, the Karius® Test lacked specificity and PPV for the diagnosis of bloodstream infections. This was especially pronounced in afebrile patients in whom clinicians did not suspect bloodstream infection. Inclusion of NCT methods within the CLABSI definition may bias national surveillance rates by including patients with low post-test probability as well as impact diagnostic stewardship efforts to reduce inappropriate blood culture collection.

Background: Healthcare facility-onset (HO) Methicillin-Resistant Staphylococcus aureus (MRSA) bacteremia represents a critical patient safety issue due to its associated morbidity and mortality. This metric is reportable to the Centers for Medicare and Medicaid Services (CMS) and impacts Leapfrog scores. However, the primary motivation for this investigation was to enhance patient safety by addressing opportunities for improvement identified through reporting trends. This project sought to identify root causes and implement targeted quality improvement measures to strengthen HO MRSA bacteremia prevention efforts. Method: A standardized root cause analysis (RCA) template was developed and applied across a tri-county region with nine acute care hospitals. The template included 58 variables based on local and national MRSA prevention measures and National Healthcare Safety Network (NHSN) recommendations. Cases meeting NHSN HO MRSA criteria were included in the analysis. Infection preventionists reviewed electronic medical records and documented findings using the RCA template. Abstracted data were analyzed by the hospital epidemiologist using Excel QI macros. The RCA findings highlighted gaps in peripheral intravenous line (PIV) care and maintenance as potential contributors to bloodstream infection risk. Building on these findings, a targeted nursing survey was conducted to identify barriers, gaps, and opportunities for improvement in PIV care practices, further informing the development of actionable quality improvement interventions. Result: Thirty-two HO MRSA cases were reported in 2023, 38.9% of which involved blood cultures with no other identified source. Specimen collection dates clustered around line days 4-10 and 18-22. Eighteen cases documented catheter-related issues, primarily drainage and infiltration at PIV sites. The RCA findings prompted a nursing survey to investigate PIV care practices. Survey responses revealed inconsistencies in maintenance practice, variation in documentation and monitoring, and requests for increased training and refresher sessions. These insights validated the RCA findings and informed the design of targeted interventions aimed at improving PIV care. Conclusion: HO MRSA bacteremia prevention requires a comprehensive approach that prioritizes patient safety while leveraging RCA findings and frontline staff input. The RCA findings and nursing survey have provided critical insights into gaps in PIV care and maintenance, laying the foundation for actionable quality improvement measures. Planned interventions, including re-education on PIV best practices, addressing survey-identified barriers, and implementing a bloodstream infection prevention bundle, are set for implementation in the next calendar year. These efforts aim to strengthen HO MRSA bacteremia prevention and improve patient outcomes.

Objectives: To characterize the incidence and contributing factors related to hospital-onset bloodstream infection (HOBsi) in a nine hospital healthcare system. Background: Bloodstream infections that develop during hospitalization are critical measures of healthcare quality. Though these events are measured in part through CMS reports of central line-associated bloodstream infections (CLABSIs) and MRSA bloodstream infections. A newer metric has been introduced by National Healthcare Safety Network (NHSN) to measure any case of bloodstream infection with onset on or after hospital day four. There is no established benchmark rate for HOBsi and its clinical understanding remains complex. Methods: Positive blood cultures obtained on or after hospital day four from nine hospitals across northeast and central Pennsylvania were included in this study, spanning July 2021 to June 2024. Cases were classified based on NHSN criteria: primary bloodstream infections (BSIs), CLABSIs, mucosal barrier injury-related infections, and secondary bacteremia with identified sources (e.g., pneumonia, urinary tract infections, gastrointestinal infection or surgical site infection). Results: A total of 739 HOBsi cases occurred in 1,186,510 patient days over three years, for a rate of 6.13 (95% confidence interval 5.69 to 6.59). The rates varied significantly by hospital unit type (p=0.002) (Figure). Oncology wards had the highest HOB rate (21.1 infections per 10,000 patient days), followed by critical care units at 11.5. Behavioral health and obstetric wards had the lowest HOB rates. When location type was considered, the rates between hospital campuses were not significantly different. In multivariate regression, the central-line device use ratio further influenced the HOBsi rate (p=0.002). Primary BSIs accounted for 49.3% of cases, while 22.1% met the criteria for CLABSI. When NHSN-defined source was found (secondary BSIs), pneumonia was the most common source (6.5%), followed by urinary tract infections (5.5%), gastrointestinal tract infections (3.5%), surgical site infections (3%), and other sources (6%). Mucosal barrier injury-related HOBsi comprised 4.2% of cases. Conclusion: This quality measure significantly expands the scope of infection events over CLABSI. HOBsi is closely associated with the hospital location type. Device use may further stratify for severity. This study establishes some initial benchmarks. Understanding the likely source of bacteremia will be important in finding ways to target strategies to reduce HOBsi.

Background: Upper respiratory infections (URIs) are a common cause of outpatient visits in adults. While most URIs are viral, antimicrobial prescribing rates remain high. The COVID-19 pandemic disrupted usual practices, necessitating an evaluation of the post-pandemic landscape for antimicrobial prescribing for URIs. This study sought to characterize factors contributing to variability in utilization in a large multi-state health system. Methods: Retrospective analysis of antimicrobial prescribing in patients ≥18 years of age for URI diagnosis codes in 863 outpatient sites (eight states), including office visits, urgent care, and telemedicine between July 1, 2023 to June 30, 2024. Primary outcome was antimicrobial prescribing rates for URIs overall and by individual URI diagnosis (sinusitis, bronchitis, pharyngitis, otitis media). HEDIS definitions were applied where appropriate. Logistic regression machine learning models were used with SHapley Additive exPlanations (SHAP) analysis to show feature contributions to antimicrobial prescribing. Results: A total of 84,724 patient encounters were included with four URI diagnoses. Antimicrobial prescribing rates varied by diagnosis (sinusitis: 60%, bronchitis: 48%, pharyngitis: 33%, otitis media: 35%, p<0.001). Prescribing ranged from 37%-58% across states (p<0.001). Sinusitis diagnosis and specific states had the strongest positive associations with antimicrobial prescribing, while race and social vulnerability index (SVI) were not associated. Conclusions: In this study in a large multi-state US health system, antimicrobials were most commonly prescribed for patients with sinusitis. Regional variation was also associated with increased prescribing. These data support efforts to standardize practices and address clinical variation.

Background: Antimicrobial resistance (AMR) is one of the most pressing health challenges of our time, fueled by the widespread misuse and overuse of antibiotics. Tackling this issue requires accurate, real-world data on how antimicrobials are prescribed and used. Point Prevalence Surveys (PPS) have become invaluable in this effort, offering a clear picture of prescribing practices and guiding the development of effective stewardship programs. This study focuses on antimicrobial use in three healthcare facilities in Ekiti State, Nigeria, leveraging the Global-PPS methodology to uncover patterns, pinpoint gaps, and identify opportunities to improve prescribing practices and support the fight against AMR. Method: This study took a hands-on approach to understanding antimicrobial prescribing practices in Ekiti State by using the well-established Global-PPS protocol. Three healthcare facilities - one each from the tertiary, secondary, and primary levels-were carefully selected to provide a broad view of prescribing behaviors. Data were gathered using standardized tools to capture key details such as patient demographics, reasons for antimicrobial use, prescribing patterns, and adherence to clinical guidelines. Descriptive statistics were used to summarize the trends, while comparisons across the facilities highlighted important differences. To ensure the findings were practical and relevant, we worked closely with the relevant MDAs, fostering a collaborative effort that added depth and context to the study. Results: Preliminary findings revealed significant variations in antimicrobial prescribing patterns, with the tertiary facility showing 75% adherence to stewardship protocols, compared to 45% and 30% in secondary and primary centers, respectively. Factors contributing to inappropriate prescriptions included limited diagnostic access (tertiary - 85%, secondary - 50%, primary - 25%), inadequate guideline dissemination (tertiary - 90%, secondary - 40%, primary - 20%), and insufficient prescriber training. Empirical therapy without justification was common, accounting for 60% of cases in secondary and 75% in primary centers. These gaps underscore the need for targeted interventions to improve prescribing practices. Conclusion: This study highlights the pressing need for customized antimicrobial stewardship programs in Ekiti State, Nigeria. By shedding light on prescribing habits and identifying critical gaps, these findings pave the way for meaningful, locally relevant interventions that encourage responsible use of antibiotics. Strengthening healthcare capacity, expanding access to diagnostic tools, and fostering adherence to treatment guidelines are essential next steps. These efforts not only hold the promise of improving patient care in Ekiti State but also contribute to the broader fight against antimicrobial resistance.

Background: Central line-associated bloodstream infections (CLABSIs) are monitored in U.S. hospitals using the National Healthcare Safety Network (NHSN) surveillance definitions. This standardization has enabled interfacility comparisons of CLABSI rates and established CLABSIs as a nationally recognized healthcare quality and patient safety indicator. Since CLABSI prevention efforts focus on infections meeting the NHSN definition, fewer resources are allocated to address other bacteremia sources, potentially missing opportunities for improvement. Methods: The review included hospitalized patients with an eligible central line and ≥1 positive blood culture on hospital day ≥ 3 in 2024. Trained infection preventionists (IPs) applied the NHSN surveillance definitions to classify positive blood cultures. IPs then gathered clinical information by reviewing the patients’ medical history, interventions, imaging tests, antimicrobial treatments, and direct caregiver engagement, used it to determine the likely clinical sources for bacteremia, and classified them according to NHSN categories. The concordance in classifying positive blood cultures using the NHSN surveillance definition alone versus with clinical input were compared. Results: Of the 136 eligible cases that IPs reviewed in 2024, 92 (67%) had concordant classifications as CLABSI (24), mucosal barrier injury (MBI) (13), secondary bacteremia (28), contaminant (25), or other (2). Of the 29 CLABSIs that met only the NHSN surveillance definition, 15 were associated with a clinical secondary source, 8 with a clinical MBI episode, 5 as continuation of previous infection or present on admission, and 1 as clinical contaminant. The 83 non-CLABSI bacteremia included 38 infections at other sites and 27 contaminants. Conclusion: Our analysis suggests that using NHSN surveillance definitions results in significant overreporting of CLABSIs in pediatric patients. Overreporting may be due to factors unique to the pediatric population, such as the inability to communicate clinical symptoms and the normal physiologic lack of signs needed to meet NHSN definitions. A focus on all BSIs could provide a greater benefit towards hospital harm reduction activities by focusing on the likely true source of bacteremia. Compared to CLABSIs, patient harm from contaminated blood cultures and infections with secondary bacteremia may be more prevalent and require a greater focus on prevention.

Background: Carbapenem-Resistant Enterobacterales (CRE’s) are an imminent and growing threat to our healthcare system, especially those in Long Term Care Facilities (LTCF). Most patients with CRE in the US are diagnosed in hospitals but often discharged to LTCF’s. But how willing and prepared are LTCF’s to take and effectively manage CRE patients? We conducted a multi-center survey of 200 LTCF’s across 4 states (CT, CA, PA, TX) to assess their willingness to admit and preparedness to manage CRE patients. Objective/methods: A questionnaire was sent to 200 consenting facilities asking about willingness and readiness to manage a CRE patient. We excluded LTAC’s and SNFv which tend to have more exposure to CRE and thus more open to accept CRE patients. Readiness was measured by capacity built around CDC recommendations for CRE management and prevention in LTCF. Survey results were analyzed using SAS inc. Results: Of the 200 surveys sent, 168 were completed and returned. Eighteen (18) were excluded for incompleteness or unclear responses. Of the 150 facilities included in the analysis, only 18 (12%) said they have had experience managing a CRE resident and 41(27%) said they would accept CRE patients. Most common reasons for unwillingness to accept CRE patients were lack of private rooms, fear of causing an outbreak and not being prepared to handle such cases. As for readiness to handle CRE patients 71(47%) said they had a CRE policy, 45 (30%) had contingent plans for how to effectively isolate CRE patients, 60 (40%) said they had isolation signage for CRE, 38 (25%) had cleaning and disinfection supplies for CRE, 21 (14%) had contingent plans for surveillance testing if that were needed. A majority 145 (97%) were aware to both notify public health if they have a case and to use an inter-facility form when transferring the patient to another facility. Conclusion: Our study, though small in size, highlights how unwilling and unprepared a lot of LTCF’s are to take on CRE patients. We also highlight some of the barriers and gaps in preparedness that can be addressed to build the capacity of LTCF’s to take in and manage CRE residents effectively.

Background: Between October 2023 and July 2024, Methodist Hospital Specialty Transplant (MHST, San Antonio TX) experienced a cluster of five infections with Salmonella enterica serotype uganda among hospitalized kidney and liver transplant patients. All patients were symptomatic and specimens included blood, stool and urine. Salmonella enterica serotype uganda is rare with only a few reported outbreaks in the literature with none from healthcare settings. Methods: Investigation focused on two hypotheses: 1) a source within the facility was causing broad exposure but only severely immunocompromised patients were becoming symptomatic or 2) The clinical management of certain transplant patients is creating a risk of reactivation of Salmonella sp. The case definition was any solid organ transplant patient with a positive culture result (any specimen source) for Salmonella enterica serotype uganda post-transplant (no defined time) with or without symptoms who had a hospitalization at MHST after October 2023. The response focused on horizontal control measures (foundational infection prevention practices, water management), vertical control measures (food and nutrition services, patient screening) and epidemiologic descriptive analysis. Findings: Whole genome sequencing identified the five cases to be from an identical species. Cases occurred among kidney and liver transplant patients in roughly the proportion to the underlying census of these patients. No clinical or nutritional product or service was identified that would expose risk to transplant patients exclusively. There were no commonalities among the cases in relation to clinical care, procedures, or type of immunosuppression. Screening was performed for twenty-eight patients (either pre-liver transplant, post liver transplant or post kidney transplant) hospitalized between September and October 2024 with either chronic diarrhea or acute loose stools, none of which were positive for any species of Salmonella. Inspections of the kitchen showed opportunities around staff attire, food handling, food storage and the physical environment. Compliance to infection prevention assessments was 71% initially but improved to above 90% by early October 2024. Hand hygiene by food handlers after the handling of raw meat was low in July and August 2024 at 25% and 37%, respectively. After targeted interventions, compliance increased to 80% by September 2024. Conclusion: Following interventions, no additional healthcare-associated Salmonella sp cases in transplant patients were noted after July 2024. While a common source for these cases was suspected, none was definitely identified. While it was not possible to make a definitive conclusion, evidence suggests that the transplant population had a unique vulnerability to this species of Salmonella.

Clozapine is the gold standard for treatment-resistant schizophrenia. In the setting of malignancy with concurrent anti-cancer agent use, clozapine use may be of increased concern. Clozapine cessation holds its own risks. This study aims to systematically review all cases of concurrent pharmacotherapy with clozapine and anti-cancer agents and analyze the psychiatric and physical health outcomes. PubMed, EMBASE, CINAHL, and PsycINFO databases were searched from inception to February 2025. Descriptive statistics and narrative analysis of the included cases occurred. There were 53 cases of clozapine use with anti-cancer agents, with a male to female ratio of 1.7:1 and a mean age of 45.0 years. In 30 cases, clozapine was continued without interruption, and in additional 16 cases, clozapine was recommenced after a period of interruption. In cases with clozapine interruption or discontinuation, 90% noted significant deterioration in mental state despite alternative antipsychotic treatments. There were 34 cases of neutropenia, mostly (94%) in the setting of cytotoxic chemotherapy, with low rates of neutropenic complications. The successful continuation of clozapine with anti-cancer agents can occur, although risk-benefit analysis taking into account individual, clozapine, psychiatric, and physical health factors is required. Consideration of prophylactic neutropenia protective measures should form part of the discussion with the individual and their family.

Background: Skilled nursing facilities (SNFs) face many challenges implementing robust infection prevention and control (IPC) programs. The Philadelphia Department of Public Health (PDPH) partnered with APIC Consulting Services, a wholly owned subsidiary of The Association for Professionals in Infection Control and Epidemiology (APIC), to provide IPC mentoring to Philadelphia SNFs. The objective of the program was to strengthen IPC capacities by providing an in-depth IPC assessment followed by an action plan and longitudinal infection preventionist (IP) support to mitigate identified gaps. Methods: A health equity framework based on area deprivation index (ADI), percent of residents on Medicaid, and Centers for Medicare & Medicaid (CMS) star rating was developed to identify priority SNFs for recruitment into the voluntary program. Participating SNFs received a three-day onsite IPC assessment with an expert IP consultant using an expanded version of the Centers for Disease Control Infection Control Assessment and Response (ICAR) tool. Assigned consultants provided mentorship and education for the SNF IP for up to six months. Each facility identified 4-5 focus areas and co-developed an action plan with the consultant. SNF assessment data collected July 2023 -May 2024 were analyzed to assess IPC gaps across facilities. Results: Participants included 11/46 (24%) Philadelphia SNFs, including 8/18 (44%) priority facilities. Median facility size was 189 beds and median census was 164 residents. Program completion rate was 73%. Consultants performed 66 onsite visits and 26 remote visits, totaling over 1,752 hours of support. Median number of IPC gaps identified was 79 (IQR: 57-84), most frequently within the domains of environmental cleaning and disinfection (13%); water management (10%); and training, auditing, and feedback (9%). Common facility-chosen action plan focus areas included disease surveillance (24%), antibiotic stewardship (16%), and hand hygiene (13%). Main barriers to program completion included lack of leadership support (18%) and staff turnover (9%). Conclusions: Expert-driven longitudinal support can be an effective strategy for enhancing IPC capacity within low resourced SNFs and a data-based health equity framework can be used to prioritize facilities for support. Through targeted mentorship, this program identified and addressed gaps in IPC practices and fostered a culture of safety. Most common action plan focus areas selected by the facilities did not align with IPC topic areas where most recommendations were given, highlighting potential SNF IPC program areas that may be challenging for facilities to address and where further education and resources are needed.

Background: Gaps in knowledge and compliance regarding control of Candida auris contribute to ongoing spread in healthcare facilities, but few studies have evaluated barriers to effective prevention measures. Methods: We assessed the knowledge, attitudes, beliefs, and practices for control of C. auris among frontline healthcare workers at 2 long-term acute care hospitals (LTACH) with high admission prevalence of C. auris in the Chicago, Illinois region. Surveys included 92 questions including the following subjects: participant demographics; awareness of multidrug-resistant organisms [MDRO]; attitudes and beliefs regarding C. auris; motivation for using and compliance with personal protective equipment [PPE]; knowledge of C. auris prevention measures; perceived barriers and facilitators of C. auris prevention; sources of education and training; and preferred learning styles. Responses were measured on a 5-point Likert scale. Anonymous online surveys were administered during the one-month study period Recruitment efforts included posters, fliers, email, and in-person rounds with the LTACH infection preventionist. Participants were eligible to win a gift card upon survey completion. Only complete surveys were analyzed. Results: Fifty-three surveys were completed (estimated 12% response rate across all facility staff) with respondents identifying as 92% female, 43% nurses, and 60% with >10 years of experience in their current role. Participants were familiar with commonly identified MDROs (i.e., Clostridoides difficile [98%], methicillin-resistant Staphylococcus aureus [88%]) but were less aware of extended-spectrum β-lactam-resistant (68%) and carbapenem-resistant pathogens (56-79%) (Figure 1). Participants felt that their actions helped prevent C. auris spread (85%) but were less confident when asked whether C. auris is a problem at their own hospital (53%). Participants were able to successfully identify most prevention strategies for C. auris (≥72% correct for all measures). The highest ranked barriers to C. auris prevention were understaffing (63%) and inadequate training (51%) (Figure 2). Information regarding C. auris was most commonly obtained through training provided within their hospital (62%) and from coworkers (45%). Participants responded that they prefer to learn about infection prevention through in-person teaching by experts at their facility (83%) or from another institution (79%), although self-learning styles were also popular (67-73%) (Figure 3). Conclusion: We identified perceived barriers to effective C. auris prevention among frontline healthcare workers in 2 LTACHs. While staff members successfully identified most prevention strategies for C. auris, they may benefit from enhanced education and training programs that support multiple learning styles.

Background: Antimicrobials are among the most prescribed medications in the hospital setting and intravenous antimicrobial use is associated with increased carbon emissions due to use of single-use disposable products for packaging, preparation, and administration. IV to PO antibiotic switch has been associated with lower waste and emissions and lower healthcare costs. This project aims to assess the effectiveness of pharmacist interventions in switching from intravenous to oral antibiotics and estimate emissions reductions. Methods: Our study population included adult patients hospitalized between October 1, 2023 and September 30, 2024 in one of twelve medical centers operating within a large, integrated healthcare system in Northeast Ohio. The primary intervention phase involved reinforcement of a pre-existing policy within our hospital system allowing pharmacists to convert certain highly bioavailable agents from IV to PO based on clinical criteria. The second intervention phase occurred as part of the hospital response to the nationwide IV fluid shortage beginning at the end of September 2024. We determined the rate of interventions occurring within the pre-intervention period and applied this rate to the intervention cohorts to determine what the expected number of interventions would be during these periods if the interventions would have had no effect. From the total days of therapy for each agent for each period, we estimated the total carbon emissions for each period, using our antimicrobial carbon emissions calculator. Results: Compared to the pre-intervention group, the rate ratio for the second intervention phase was 2.97 (95% CI 2.61 to 3.37). The second intervention group rate versus the first intervention rate was 1.49 (95% CI 1.26 to 1.77). Using the difference between the actual and expected number of pharmacy interventions, the potential DOT saved using conservative (assuming 1 pharmacy intervention saves 1 DOT) and liberal (assuming 1 pharmacy intervention saves 3 DOT) estimates was determined, as well as the actual DOT saved based on the antimicrobial administration data. These values were used to calculate the carbon dioxide emissions and equivalents potentially and actually saved (Figure 2). The total actual emissions saved was less than both conservative and liberal estimates for post-intervention phase 1 versus pre-intervention phase, but it surpassed both estimates for post-intervention phase 2 versus pre-intervention phase. Conclusion: This is one of the first projects to estimate carbon emission reductions associated with IV to PO antibiotic switching. Future research should focus on identifying further opportunities to promote sustainable policies and measuring their impact.

Background: Device-associated infections, such as catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI), increase patient mortality, morbidity, and length of stay. These infections are best prevented through appropriate use and maintenance of the devices. There is often a lack of accountability regarding the appropriateness of central lines and urinary catheters. Our team’s goal was to develop an approach that validates device necessity each day to reduce device utilization and ultimately decrease CAUTIs and CLABSIs. Methods: A multidisciplinary team, including infection prevention (IP), facility leaders, unit nursing leaders, performance improvement coordinators, and providers, implemented a hospital-wide (excluding the neonatal intensive care and maternity units) daily Device Safety Huddle (DSH), in a 360-bed hospital in September 2024. IP facilitates the meeting, and unit leaders or their delegates are expected to report daily on the number of central lines and urinary catheters on their unit. Leaders also report any concerns related to site or type, actual necessity, plans for removal, and barriers to removal. IP spot checks various charts to ensure that device necessity correlates with unit reporting. The team compared device utilization rates (DUR) and infection rates for CAUTI and CLABSI pre (January - August 2024) and post-intervention (September - December 2024). Statistical analysis was applied to assess the differences between both groups. Results: DUR for urinary catheters reduced from 18.1 per 100 patient days pre-intervention to 15.1 (IRR 0.83, p < 0 .0001) post-intervention, with similar reductions calculated for central lines from 15.6 per 100 patient days to 13.8 (IRR 0.89, p < 0 .0001). Infection rates remained stable for CAUTI (0.57 vs 0.43/1000 catheter days, IRR 0.73, p=0.77) and CLABSI (0.69 vs 0.74/1000 central line days, IRR 1.07, p=0.89) post-intervention (Table 1). Conclusions: Implementing a daily DSH helped improve accountability related to device necessity and decreased device utilization. The infection rate changes are not statistically significant at this time and will continue to be evaluated for long-term impact. The inclusion of administrative and director-level leadership is essential for accountability and the success of the intervention.

Background: There are ongoing significant increases in antimicrobial resistant infections in hospitalized patients in the United States, emphasizing the importance of antimicrobial stewardship initiatives like appropriate antimicrobial use and accurate laboratory detection of infections. The special population of obstetric patients has received relatively limited focus in prior reports about antimicrobial stewardship opportunities. Methods: A retrospective observational review was conducted through a single large healthcare system’s electronic medical record to evaluate antimicrobial use in peripartum patients, defined as 30 days pre- or post-delivery. Our hypothesis was that most antibiotic use could be attributed to American College of Gynecology (ACOG) recommended therapy for common situations such as group B Streptococcus (GBS) prophylaxis, surgical site infection (SSI) prophylaxis, or intra-amniotic infections (IAI). Data regarding antimicrobial allergies were also collected. Results: Between April 2018 and July 2024, 77,062 mother-baby dyads were identified. 40,576 (52.6%) had antimicrobial utilization peripartum. Redundant antimicrobial coverage was common; most commonly cefazolin and penicillin (n=1402) and cefazolin and ampicillin (n=675). A subanalysis of 8528 (11% total deliveries) patients receiving the most common antimicrobials demonstrated 199 separate regimens utilized, 92 (46.2%) of which had duplicative spectrum of activity. The top three regimens were cefazolin and penicillin (n=126), cefazolin and ampicillin (n=51), and cefazolin and cefoxitin (n=47). 33 (16.6%) were in line with ACOG guidelines for GBS or SSI prophylaxis or IAI. 12 of the 33 (36.4%) were ACOG endorsed regimens with duplicative spectrum of activity. Allergies were common in the subanalysis cohort; 3957 (46%) patients had penicillin allergies and 816 (9.5%) patients had cephalosporin allergies. Conclusions: An administrative review of peripartum antimicrobials indicates significant opportunities for antimicrobial stewardship, particularly around antimicrobial coverage for conditions for which there is overlapping spectrum of activity, such as GBS prophylaxis with SSI prophylaxis. There are also significant opportunities in delabeling penicillin and cephalosporin allergies as there is the lead time of the pregnancy, usually with multiple touchpoints with obstetric care providers, to explore the accuracy of the allergy label. Steps to improve antimicrobial utilization around guideline-concordant antimicrobials with overlapping spectrum of activity as well as delabeling antimicrobial allergies will lead to decreased variability in antimicrobial prescribing in this population.