Background: Chlorhexidine gluconate (CHG) bathing reduces skin bacterial colonization and reduces the risk of hospital-acquired bloodstream infections, central venous catheter-related bloodstream infections, and transmission of multidrug-resistant organisms. Although mild skin irritation to CHG is common, true IgE-mediated allergy is rare. We implemented a program to delabel low-risk CHG allergies in hospitalized patients. Methods: Patients ≥ 18 years of age admitted to inpatient cardiology or hematology-oncology units with an allergy to CHG documented in the electronic medical record were identified. A hospital epidemiologist contacted primary care teams directly, providing a personalized and collaborative approach to evaluate the listed CHG allergy. Using an algorithm devised in partnership with dermatology and allergy experts (Figure 1), guidance was tailored to the reported type of reaction. Each point of contact with care teams was considered an intervention. The primary endpoint was the number of patients for whom a CHG allergy or intolerance was removed from the medical record. Results: During a two-month period, 42 interventions for 31 unique patients reporting an allergy to CHG were performed. The cohort was fairly evenly distributed between hematology-oncology and cardiology units (52% vs 48%, respectively), and was 51% male with a median age of 63 (IQR, 20.5 years). Rash was the most frequently listed concern (58%), followed by nonspecific burning or irritation (35%). 5 patients (16%) were delabeled; of these, 2 were directly delabeled due to tolerance of other CHG products (e.g., CHG dressing), and 3 were delabeled by dermatology patch testing. There were no adverse reactions reported after CHG allergy de-labeling. Conclusion: Similar to handshake rounds for antimicrobial stewardship, collaborative and targeted education can be an effective strategy to delabel CHG allergies and intolerances.

Background: Our antibiotic stewardship program (ASP) has decreased inpatient fluoroquinolone (FQ) consumption using a prior-authorization process and physician-led audit and feedback. The objective of this project was to examine if the decrement in FQ use was associated with improvement in the FQ sensitivity rate of selected gram-negative organisms. Method: Quarterly days of therapy standardized to 1000 care-days (DOT/1000 CD) for ciprofloxacin, moxifloxacin, and levofloxacin were calculated as the measure of inpatient FQ consumption starting from quarter three of fiscal year 2012 to the end of fiscal year 2022. To evaluate resistance patterns, facility-level sensitivity rates for ciprofloxacin and levofloxacin against Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii were collected from the antibiogram published from calendar year 2012-2022. FQ sensitivities for the first half of the study period (2012-2016) were compared to the second half (2017-2022) using Chi-square tests. Results: Inpatient FQ consumption from 2012-2022 is summarized in Figure 1. After the initiation of the ASP in 2012, a gradual and steady decline in in-patient FQ use was observed. During the first four quarters, the average FQ use was 71.3 DOT/1000 CD. Lowest use was observed during 2020 calendar year, with average consumption of 19 DOT/1000 CD. FQ consumption then increased to 30.6 DOT/1000 CD (Q2-2021 to Q4-2022). Overall, there was a decrease of 40.7 DOT/1000 CD; a 56.16% decrease in FQ consumption over the 11-year period. E. coli and K. pneumoniae sensitivity to FQs remained stable over time with a mean of 77% and 95%, respectively (see Table 1). We observed statistically significant improvements in FQ sensitivity for P. aeruginosa from 75% to 89% (p-value Conclusions: We found differing effects of decreased inpatient FQ use on antibiogram sensitivities between four gram-negative organisms. Significant improvements in FQ sensitivity were observed in P. aeruginosa and A. Baumannii reverting to high level sensitivity but not for E. coli or K. pneumoniae. These data support the effectiveness of ASPs in reducing FQ use and improving some FQ sensitivities.

Background: Carbapenem-resistant Enterobacterales (CRE) are significant healthcare-associated pathogens. Liver transplant (LT) recipients are particularly vulnerable to CRE acquisition due to frequent hospitalizations, extensive antibiotic exposure, and prolonged stays in intensive care units. This study aimed to develop and evaluate prediction models for CRE acquisition in LT recipients at a hospital where more than 500 LT surgeries are performed annually. Method: This case-control study retrospectively analyzed the electronic medical records of 1,250 adult LT recipients (250 CRE-positive and 1,000 CRE-negative cases) at a 2,768-bed tertiary hospital in Seoul, Korea, from February 2020 to February 2024. Data imbalance was addressed using the synthetic minority over-sampling technique, and missing values were handled through median imputation and k-nearest neighbor imputation methods. Prediction models were developed using logistic regression, random forest, and extreme gradient boosting (XGBoost) algorithms, with optimal models selected through 5-fold cross-validation and recursive feature elimination. Model interpretability was enhanced using Shapley additive explanations and partial dependence plot analyses. Result: Of the CRE isolates, 94% were carbapenemase-producing Enterobacterales, with Klebsiella pneumoniae comprising 55.7% of all CRE isolates. Univariate analysis revealed significant differences between groups in LT month (June-September, p<.001), mechanical ventilation over 72 hours (p=.002), and model for end-stage liver disease (MELD) score (p=.041). The XGBoost model, selected as the final model, demonstrated strong specificity (0.848) and a high negative predictive value (NPV 0.830) for identifying non-carriers, although its overall predictive power was limited. Features used in the XGBoost model included LT month, third-generation cephalosporins, and the presence of hepatocellular carcinoma, all of which showed a positive correlation with CRE acquisition. In contrast, mechanical ventilation over 72 hours and living donor LT exhibited negative correlations. Viral hepatitis and body mass index were included in the model, but their impact on CRE acquisition risk remained unclear. Notably, the negative association of mechanical ventilation contrasts with findings from previous studies, highlighting the need for further investigation. Conclusion: This study demonstrates the clinical relevance of machine learning models in predicting CRE acquisition among LT recipients. The XGBoost model showed high specificity and NPV, indicating its potential to effectively identify low-risk patients. Future studies could benefit from adopting prospective, multicenter designs to clarify causal relationships and improve model performance.

Background: Acute gastroenteritis and diarrheal illnesses have a significant burden on the United States healthcare system, with over 500,000 estimated hospitalizations annually. Testing for these conditions is often ordered inappropriately at significant cost to the healthcare system. This study aimed to determine the appropriateness of ordering of gastrointestinal PCR panel (GIP) testing in our hospital system to guide improvements in ordering practices. It also aimed to evaluate the impact of a GIP in our system. Method: This was a retrospective chart review with the objective of quality improvement. The appropriate measures for ordering a GIP test included documentation of diarrhea in addition to fever, blood in stool, signs of sepsis or immunocompromise and without history of laxative use in preceding 48 hours. The result of a positive versus negative GIP test was measured in terms of its effect on isolation time and appropriate de-escalation of antibiotics. Result: Of the 402 records which were reviewed, 204 (50.7%) were deemed to have had an appropriately ordered test per our criteria. However, of these patients, 21 were noted to have either been on tube feeds or had received bowel regimen medications within the past 48 hours. When these patients were excluded, this left 183 (45.5%) patients with an appropriately ordered GIP test. Of note, 16 of these patients had a positive concomitant C. difficile test. Of the 93 (23.1%) positive tests, only 36 positive results were from appropriately ordered tests of which 9 tests impacted clinical management. Of the 57 remaining tests, 11 impacted clinical management. A negative test led to discontinuation of isolation precautions in 159 (76.1%) patients who had isolation placed for diarrheal illness prior to testing. Negative tests also led to discontinuation of antibiotics in 51 (39.5%) patients. There was no difference between these groups regardless of whether the test was ordered appropriately or not. Conclusion: The GIP test to detect a variety of gastrointestinal pathogens is not being ordered appropriately in our health system over half the time. It bears further investigation as to whether the monetary cost to patients and the health system of this test is offset by the apparent antibiotic stewardship and cost benefits in discontinuing isolation precautions and antibiotics. Interestingly, testing appeared to have utility regardless of appropriateness. Based on this finding, an updated set of guidelines to educate physicians in the appropriate ordering and interpretation of this test is required.

Background: Older adults are prescribed more antibiotics than younger populations and face increased risks of antibiotic-related adverse events. Identifying high-volume prescribers (HVPs) through Medicare Part D (MPD) datasets and engaging them through targeted intervention, such as peer-comparison audit and feedback, is a way to impact antibiotic prescribing. Methods: We analyzed the 2022 publicly available Centers for Medicare & Medicaid Services MPD Prescribers by Provider dataset to summarize the data overall and identify HVPs within each specialty. HVPs were classified as prescribers in the top 10% of antibiotic prescribing by volume within their specialty. Prescribers with 1,316 Minnesota prescribers in 2022 were considered HVPs (top 10% by volume by specialty). After removing certain specialties and those with low prescribing rates, 995 HVPs met criteria and were mailed feedback letters, with 4.32% (43 letters) lost to follow-up. These HVPs were responsible for 28.7% of antibiotic prescriptions for Minnesota’s MPD beneficiaries in 2022. The median antibiotic prescribing rate of these HVPs was 1.8 times higher than that of lower-volume prescribers (Table 1) (p To date, 18 letter recipients responded to the feedback survey, with 22.2% intending to review their current prescribing habits, 22.2% reflecting that there is room for improvement in their prescribing, and 55.6% have accessed or intend to access AS resources. Conclusion: This audit and feedback initiative demonstrated that the MPD dataset can be used as a low-cost method to provide peer-comparison feedback to HVPs. By reaching providers responsible for nearly 30% of antibiotic prescriptions among MPD beneficiaries in Minnesota, this intervention has potential to influence prescribing behaviors. Further work will evaluate feedback and focus on specific provider specialties and drug classes.

Background: Pediatric oncology patients receive significant care in outpatient settings using central venous catheters (CVC) for chemotherapy, blood product transfusions, parenteral nutrition, and blood tests. Data about the rate of ambulatory central line associated bloodstream infection (CLABSI) is limited and its prevention activities have been derived from the inpatient setting with potentially limited applicability to the outpatient care. In this quality improvement project, we used apparent cause analysis (ACA) to better identify barriers and facilitators to reduce ambulatory CLABSI in a pediatric oncology center. Methods: Since January 2024, ambulatory CLABSI events were identified by reviewing positive blood culture reports in an electronic surveillance system. The infection preventionist (IP) classified events as CLABSI or mucosal barrier injury (MBI) laboratory confirmed bloodstream infection (LCBI) using modified NHSN definitions. Ambulatory CVC-days were reported electronically for active patients with CVC and outpatient encounters. In March 2024, ACA investigation of patients admitted for ambulatory CLABSI was implemented using an electronic tool designed to address questions related to CVC care in the outpatient or home care setting. The ACA team consisted of an IP, outpatient nurse, and inpatient nurse. The team visited with the caregiver and/or patient for an interview and used this opportunity for just-in-time teaching to patient caregivers and staff. The results were entered into a database for lessons learned. Results: From January to November, there were 70 events classified as CLABSI in 67% and MBI-LCBI in 33%. Median (range) age was 5.0 (0.5-22.0) years. 39% had leukemia, 43% solid organ or brain tumor, and 14% were transplant recipients. 53% were neutropenic. Coagulase-negative staphylococcus was the most frequently isolated organism in 21% of patients followed by Escherichia coli in 17%. 47% had an in-person ACA interview; of which, 43% reported caregivers performing CVC care at home and 67% reported having been trained in the past 90 days. Table shows lessons learned from the ACA of the ambulatory CLABSI. Conclusion: ACA of ambulatory CLABSI is an important strategy to identify challenges of CVC care in the outpatient or home setting and to guide the design of a targeted improvement plan to reduce ambulatory.

Background: Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections (HAIs), often resulting in prolonged hospital stays, increased healthcare costs, and additional clinical interventions. The COVID-19 pandemic introduced new challenges to infection prevention, with global reports indicating increased rates of certain HAIs, such as ventilator-associated pneumonia and bloodstream infections, due to healthcare strain and the intensified use of invasive devices. However, trends in CAUTI rates during the pandemic varied across healthcare settings. Methods: This retrospective study was conducted at the University of Iowa Health Care Medical Center, an 866-bed academic hospital, from 2018 to 2023. Manual chart reviews of CAUTI cases reported to the National Healthcare Safety Network (NHSN) were performed to collect data on patient demographics, medical histories, catheter usage, and infection prevention practices. CAUTI incidence was analyzed over time and compared with monthly COVID-19 admission rates. Results: A total of 226 CAUTI cases were identified during the study period. The average CAUTI rate per 1,000 catheter line-days declined from 1.23 in 2019 to 0.85 in 2020, but increased to 1.28 in 2021, coinciding with COVID-19 surges (Figure 1). The median patient age was 61 years, with females accounting for 56% of cases. Foley catheters were already in place upon admission in 24% of cases. Non-intensive care unit (ICU) inpatient settings accounted for 24% of catheter placements, while ICUs accounted for 18%. Additionally, 16% of cases originated from the operating room, and 7% from the emergency department. Neurologic disease was the most common admission diagnosis (27%), followed by cardiovascular disease (13%) and Hematologic/Oncologic disease (13%). Twenty six percent of cases were incontinent of urine and 24% of stool. Comorbidities included immunocompromised status (20%) and diabetes (36%). The primary indication for Foley catheter use was monitoring intake and output (42%). Of the 226 cases, 61% of patients were clinically considered to have a UTI. In-hospital mortality was 22%. Conclusion: The findings from this study provide insights into factors contributing to CAUTI at our institution. Fluctuations in CAUTI incidence, particularly during the COVID-19 pandemic, underscore the need for robust infection prevention strategies. The finding that only 61% of cases required treatment suggests urine cultures were often obtained inappropriately or positive results were not used in selected situations. This highlights an opportunity for diagnostic stewardship to improve urine culture practices. Addressing identified risk factors and enhancing catheter management are critical to reducing CAUTI incidence and improving patient outcomes.

Background: Presence and documentation of clinical symptoms of Clostridioides difficile infection (CDI) prior to diagnostic testing is not well-described. The Infectious Diseases Society of America (IDSA) guidelines recommend that patients have ≥3 episodes of unexplained loose stool in the previous 24 hours before testing. In populations predisposed to chronic non-infectious diarrhea, such as those undergoing chemotherapy or with chronic gastrointestinal (GI) illness, more explicit signs of infection may be needed. Our objective was to evaluate CDI symptoms that proceeded testing in a cohort of inpatient Veterans with chronic GI illness or undergoing chemotherapy. Methods: This retrospective cohort study included Veterans hospitalized at 8 VA facilities from January 1st, 2019-December 31st, 2022, who were tested for CDI, and were receiving chemotherapy or had chronic GI illness. Charts reviewed identified the following symptoms in the 24 hours prior to testing: greater than 3 loose stools in 24 hours, bloody stool, nausea, vomiting, abdominal pain, fever (temperature ≥100.4°F), and white blood cell count >10,000/mm3. The presence of 3 loose stools in 24 hours alone was deemed the minimal indication for CDI testing, while the presence of any additional symptoms was considered high indication for testing. CDI treatment was defined as at least one dose of metronidazole, oral vancomycin, or fidaxomicin ±7 days from testing. Chi-square tests assessed the association between indication for CDI testing and test positivity. Results: A total of 676 tests for 577 unique patients were reviewed (69.1% White, 94.5% male, mean age=68.3 years). Most had a chronic GI illness (90%); colitis, and presence of a gastrostomy were the most frequently reported. Only 14% of CDI tests were positive. The minimal indication for CDI testing was present for 243 tests (36%). 190 tests (28%) were ordered for patients with symptoms highly indicative of CDI. Of the negative tests, 55% were associated with at least one dose of CDI treatment. There was no association between test indication and test positivity (p-value=0.82). Conclusion: In a population predisposed to chronic non-infectious diarrhea, nearly two thirds (64%) of those tested did not meet the minimum requirement (3 documented loose stools in 24 hours). This may partly explain the low-test positivity rate of 14%. Over half of negative tests were associated with CDI treatment. Future work should focus on diagnostic stewardship to improve documentation of loose stool and other CDI symptoms prior to testing to reduce unnecessary testing and overtreatment.

Background: The overuse of antimicrobials contributes to the development of antibiotic resistance, the development of Clostridioides difficile infections, and increased patient morbidity and mortality. The impact of U.S. News medical school ranking on provider antimicrobial prescription is largely unknown. Our study aimed to assess whether there was a relationship between graduating from higher-ranked medical schools and the rate of prescribing antibiotics among Medicare Part D providers in the US. Methods: The ecological study obtained data from the Medicare Part D Prescribers (FY2013-2021) and the Doctor and Clinicians National repositories. The study’s main outcome was antibiotic days supplied per 100 beneficiaries. Secondary outcomes included antibiotic claims per 100 beneficiaries, days per claim, and antibiotic cost per 100 beneficiaries. A regression model was fitted to assess the relationship between provider medical school ranking and study outcomes. The study controlled for several state, provider, and patient variables. Results: A total of 197,540 providers were included (Table 1). No association was found between the medical school ranking and the rate of antibiotics days supplied per 100 beneficiaries (Table 2, Figure). Instead, the type of provider is associated with the prescription rates. Hospitalists and Emergency Medicine providers had fewer days supplied per 100 beneficiaries than Family Medicine providers. In contrast, students, more experienced providers (>20 years since medical school graduation), and females had more days supplied per 100 beneficiaries. Higher-ranking medical schools [1, 35], EM providers and hospitalists (vs. FM), and academic locations had lower claim rates per 100 beneficiaries, while students and experienced providers had higher claims. Days per claim were higher among providers from higher-ranked medical schools, more experienced providers, students, and academic locations, whereas they were lower among males, EM Providers, and Hospitalists. Costs per 100 beneficiaries were higher among students, academic locations, IM providers, and males; however, it was lower among EM and hospitalists. Conclusion: Our study showed no impact of medical school ranking on the overall rate of outpatient antibiotic prescriptions among Medicare Part D providers. While the claim rate per 100 beneficiaries was lower among providers from higher-rank medical schools compared to other providers, claims were prescribed longer, leading to similar days supplied and costs compared with other providers. This highlights the need for robust outpatient stewardship interventions and incorporating an outcome-based approach to antibiotic stewardship curricula in medical and mid-level provider schools.

Background: Catheter-associated urinary tract infections (CAUTIs) are a challenge for hospitalized patients accounting for approximately 40% of all healthcare-associated infections. CAUTI surveillance remains underdeveloped in many Sub-Saharan countries, even though identifying infections is critical to prevention and management. Standardized CAUTI surveillance among 45 LMICs conducted in intensive care units (ICUs) has demonstrated high CAUTI incidence compared to high-income countries. However, few studies have examined CAUTI in non-ICU settings in LMIC, where catheter use is common. We aimed to identify challenges in CAUTI surveillance related to documentation and antibiotic use patterns among adult inpatients in non-ICU wards in a Kenyan public hospital. Methods: Using a cross-sectional design, we retrospectively abstracted data on non-ICU adult inpatients from clinical and laboratory records. We identified patients with suspected UTI through urine culture requests from 1/1/2023-12/31/2023, whom we linked to clinical records. We abstracted data on diagnosis on admission, socio-demographics, urinary catheter indication and duration, UTI symptoms, urine culture results, and antibiotic use. This descriptive analysis summarizes characteristics of patients with suspected UTI to identify factors hindering CAUTI surveillance in non-ICU settings. Results: 293 non-ICU adult inpatients admitted to Mombasa Regional Referral Hospital had at least one urine culture request in 2023. Of these 193 (65.9%) had indwelling urinary catheters (IUC) inserted. Among those with IUC, 49.7% were female, with an average age of 51.5 years, with majority (64.8%) admitted to the medical wards; 5.2% had no recorded indication for catheterization and 82.9% had no UTI symptoms documented in the 2 days before the urine culture request. There were 124 negative cultures, 4 were determined to be contaminated, 6 did not have results on file, and 59 were positive; pathogens identified in the positive cultures included Escherichia Coli (51.8%), Klebsiella Pneumoniae (28.6%), Pseudomonas aeruginosa (10.7%), and others (8.9%) including Klebsiella Oxytoca, Acinetobacter baumanii, and Protein Mirabilis. 38.3% were prescribed intravenous antibiotics in the 7 days before the urine culture was obtained. 66.3% had no documentation of IUC removal, and 10.9% had incomplete documentation on file with missing pages. Conclusion: Myriad challenges to accurate CAUTI surveillance were identified among non-ICU patients at a Kenyan regional referral hospital. Lack of documentation of clinical symptoms makes application of standard case definitions challenging, and non-documentation of catheter removal dates hinders calculation of incidence using a catheter-day denominator. Further, the administration of antibiotics prior to urine culture hinders identification of potential source pathogens. Documentation and antibiotic administration practices are major hurdles for CAUTI surveillance.

Background: Multi-drug resistance is increasing, and insects may serve as critical reservoirs for these bacteria. While insects are part of the world’s natural flora and exist even in healthcare settings, their presence is often overlooked or disregarded. Current healthcare safety guidelines focus on keeping insects out but fail to address their potential contribution to nosocomial pathogen transmission, This study aims to determine the extent of knowledge regarding microbial transmission by insects in a healthcare setting. Methods: The systematic literature search utilized subject headings and preferred index terms such as “insects,” “microbial transmissions,” “insect vector,” “insecta,” and “cross infection” to construct a reproducible MEDLINE search within PubMed. This search was translated across Embase, CENTRAL, and select supplemental resources. Retrieved studies exceeded 1000 records, which were deduplicated using Covidence software, leaving 655 eligible articles for screening. A total of 36 peer-reviewed studies documenting insects in healthcare settings (e.g., hospitals, clinics, rehabilitation centers, ambulatory centers) were included and underwent data extraction and analysis. Excluded studies were non-English without translation or irrelevant to healthcare. Outcomes included identification of colonizing organisms, evidence of microbial transmission, and prevalence of multidrug-resistant pathogens carried by insects. Risk of bias was evaluated using the LEGEND criteria, and extracted data were synthesized following the Cochrane Review for Systematic Reviews in conjunction with the Joanna Briggs Institute (JBI) frameworks. Results: Of the analyzed studies the majority were from low- to middle-income countries and included the study of common insects such as cockroaches, ants, and various classes of flies. Studies included the examination of external surfaces and internal contents of the insects via evidence-based, aseptic collection and laboratory processes. Few studies demonstrated the likely transmission of bacteria via insect vector, though all studies demonstrated robust colonization of insect vectors with pathogenic microbes including multi-drug resistant bacteria. Conclusion: This review highlights the potential role of insects in microbial transmission in healthcare settings. However, most studies failed to establish a direct link between insects and pathogen transmission. Further research into areas such as multi-drug resistance transmission via insect vectors is needed.

Background: Sars-CoV-2, better known as COVID-19, emerged in late 2019 and was declared a pandemic in March 2020. In April 2020, it was noted that multiple children were having serious inflammatory symptoms after being diagnosed with or exposed to COVID-19. The Centers for Disease Control and Prevention (CDC) defined MIS-C with a specific case definition in May 2020 that included fever, clinical severity resulting in hospitalization, evidence of systemic inflammation, involvement of at least two organ system, and no alternative plausible diagnosis. A revised case definition was issued in January of 2023 which included subjective or documented fever, clinical severity requiring hospitalization or death, elevated C-reactive protein, new onset manifestations of 2 or more organ systems, and absence of a more likely alternative diagnosis. 2023 case definition eliminates involvement of renal, respiratory or neurologic systems. Some cases reported under the original case definition would not fit the 2023 case definition. Multisystem Inflammatory Syndrome in Children (MIS-C) symptoms can include, but are not limited to, fever, red eyes, abdominal pain, nausea, vomiting, diarrhea, and organ dysfunction. Cases have varied from mild to severe. The first case of MIS-C seen at Children’s was admitted in April of 2020. Method: Diagnosing MIS-C is not always clear cut. To help with properly diagnosing cases, a multi-disciplinary team (Team) was formed to review cases regularly before reporting to the state and CDC. The team included Infection Prevention Epidemiologists, Pediatric Infectious Disease Physicians, General Pediatric Physicians, Pediatric Cardiologists, members of the Georgia Department of Public Health State Epidemiology staff, and members of the CDC staff. Results: Initially, the Team held weekly meetings to discuss cases. As cases declined in frequency, meetings were switched to bi-weekly, then monthly, and are now held ad hoc. Between April 2020 and December 2023, a total of 1339 potential cases were reviewed, and 485 cases were confirmed as meeting case definition. Of the confirmed cases, 216 required admission to an intensive care unit (ICU). Conclusion: According to CDC representatives, the number of cases reported from Children’s was significantly higher than from comparable pediatric facilities in other parts of the country. We believe this is due to the collaborative nature of our review process and our diligence in ensuring that all patients that could possibly meet definition were reviewed, regardless of clinical diagnosis. All patients were discussed to ensure a consensus was reached prior to reporting.

Background: Tracking and reporting antibiotic use (AU) are core elements of hospital antibiotic stewardship. However, not all hospitals have the capacity to analyze AU data. The Colorado Department of Public Health and Environment and Children’s Hospital Colorado generated two automated reports of hospital AU to support antibiotic stewardship programs (ASPs) across Colorado. Methods: The first report was an AU feedback report that summarized data from the National Healthcare Safety Network (NHSN) Antimicrobial Use and Resistance Module. Distributed twice per year, it included hospital rates of AU for high-volume and broad-spectrum antibiotics compared to rates from facilities of similar type, bed size, and geographic region (Figure). We solicited feedback from users of the AU feedback report via REDCap survey. The second report (pathway adherence) summarized adherence to treatment guidelines for adult and pediatric community acquired pneumonia (CAP), adult urinary tract infections (UTI), and adult skin/ soft tissue infections (SSTI). The pathway adherence report used self-reported, deidentified, case-level data entered by hospitals into a REDCap survey, and incorporated individualized review and expert guidance to assist ASP interventions. We analyzed all data and created custom PDFs in R-Studio and R-Markdown. Results: Between May 2023 and November 2024 we distributed 272 AU feedback reports to 52/55 (94%) acute care hospitals (ACH) and 23/33 (69%) critical access hospitals (CAH) in Colorado. Participating hospitals were distributed across the state and had a median (range) bed size of 49 (8– 828). Among 14 hospitals that provided feedback, most users said AU feedback reports included meaningful visual comparisons and helpful data quality checks. Many facilities responded that they shared the AU feedback reports with hospital leadership, pharmacists, prescribers, infection preventionists, nurses and laboratory personnel, in addition to ASPs and steering committees. In October 2024, we distributed 34 AU adherence reports to seven ACH and six CAH, including: four pediatric CAP, ten adult CAP, twelve UTI, and eight SSTI reports. Conclusion: Automated AU feedback and adherence reports were feasible, scalable, and well-received. They fostered an opportunity for public health to connect with hospital ASPs and provide 1:1 mentorship. Centrally-developed, individualized reports provide an analytic service to equip ASPs with concise, comprehensive summaries of their hospital’s AU.

Background: Crisp Regional Hospital (CRH) in Georgia initiated a quality improvement project to address the excessive and inappropriate urine culture orders among inpatients. The project aimed to reduce these orders by at least 30% by June 2024, targeting the prevalent issues of increased healthcare costs and antibiotic misuse stemming from unnecessary testing. Methods: Using the Institute for Healthcare Improvement (IHI) framework, the project implemented a series of multidisciplinary strategies. These included nursing education on proper urine collection, policy updates to facilitate accurate specimen collection from specific patient groups, medical staff education on appropriateness of urine test ordering and a change in reflex criteria for urine testing. Data was analyzed using statistical process control and T-tests to assess the impact of the interventions. Results: The intervention led to a reduction in urine tests from 618 to 570. Tests reflexed to culture decreased significantly from 34.63% to 18.95% (p Conclusion: The quality improvement initiative at CRH significantly reduced unnecessary urine cultures, optimized resource use, and maintained diagnostic integrity. The interventions implemented were effective and scalable, demonstrating substantial cost savings and enhanced patient care quality. Further efforts will focus on analyzing the impact of removing pre-checked orders and implementing mandatory testing indications to continue improving urine testing practices.

Background: In 2024, an increase in colorectal surgical site infections (SSI) was identified at two AdventHealth Central Florida Division campuses. Control charts revealed this as a special cause variation, prompting an in-depth investigation into potential contributing factors and modifiable risks. Methods: A detailed review of 14 SSI cases (five at Campus A and nine at Campus B) was conducted. The analysis focused on key perioperative practices, including chlorhexidine gluconate (CHG) application, postoperative blood glucose control, perioperative antibiotic administration, hair clipping techniques, skin preparation protocols, and postoperative temperature monitoring. A secondary analysis was conducted by the surgical team on intraoperative factors and operative techniques. Results: The investigation revealed that for both campuses, over 80% of SSIs were linked to defects in perioperative antibiotic administration, postoperative glucose control, and CHG application. At Campus A, primary gaps were identified in postoperative glucose control, perioperative antibiotic administration, and CHG application, while at Campus B, issues stemmed from CHG application, postoperative glucose control, and hair removal practices. Conclusion: Corrective actions were recommended to address these gaps, including enhanced pharmacy involvement to ensure timely and appropriate antibiotic administration, standardized processes for glucose monitoring and CHG application, and standardization of adherence to WHO guidelines. A continuous audit system with regular feedback was proposed to monitor compliance and drive further improvements. This analysis also revealed the importance of creating a robust process metric dashboard to monitor and provide the ability to detect variation in perioperative processes that could lead to an increase in SSI. It also highlights how quality improvement science has great applicability in infection prevention and hospital epidemiology. These measures aim to significantly reduce SSI rates and improve patient care.

Background: Tuberculosis transmission in healthcare is poorly understood. Exposure definitions for patients and healthcare workers tend to be based on custom rather than data leading to many people being flagged for evaluation despite few infection transmission events. We reviewed the medical literature to identify and quantify risk factors for tuberculosis transmission in healthcare to guide risk-stratification and inform exposure definitions. Methods: We reviewed MEDLINE, EMBASE, CINAHL and Cochrane databases from inception to December 10, 2024. We included studies reporting tuberculosis transmission from infected adult patients to healthcare workers and other patients in both inpatient and outpatient settings. We evaluated 12 transmission risk factors: contact factors (exposure duration, proximity of exposure, mask use, room ventilation), patient factors (smear positivity, NAAT positivity, cavitary pulmonary disease, respiratory symptoms), and procedure factors (intubation, bronchoscopy, sputum collection, and other procedures). Results: A total of 6,695 studies were identified of which 49 met inclusion criteria. Contact factors associated with increased risk of transmission included poor room ventilation (≤ 2 air exchanges per hour, 60-70% air recirculation without high efficiency filtration, high ambient carbon dioxide levels with median 660-800 parts per million) and positive pressure air flow from poorly ventilated rooms to nearby clinical spaces. Most ventilation-related transmissions occurred before modern healthcare ventilation standards were implemented. Sustained proximity to infected patients was associated with patient-to-patient transmission via shared rooms (4 transmissions/90 exposures, minimum exposure ≥16 hours) and prolonged residence adjacent to a poorly ventilated standard pressure room (42 transmissions/430 exposures, minimum exposure ≥24 hours). Amongst 766 cases of tuberculosis transmission from patients to healthcare workers, risk factors included prolonged patient contact (median 6 hours, minimum 30 minutes), failure to wear an N95 respirator, and face-to-face patient care (28% of transmissions were associated with face-to-face patient contact, 21% of transmissions were associated with working on the same unit without direct patient contact, and contact details were unknown in 52% of transmissions). Patient factors associated with increased transmission included cavitary disease (OR 1.90, 95% CI 1.26-2.84). Transmission risk was similar for smear-positive and smear-negative patients undergoing aerosol-generating procedures without airborne precautions (17/111 smear negative exposures led to transmission vs 32/166 smear positive exposures, 15% vs 19%). All transmissions to healthcare workers associated with intubation, bronchoscopy and induced sputum collection occurred without airborne precautions. Conclusions: Detailed review of the circumstances around nosocomial tuberculosis exposure helps identify transmission risk factors that can inform more evidence-based, detailed and individualized exposure definitions.

Background: From October 2023-June 2024 increased surgical site infection (SSI) rates were identified in our large pediatric hospital, 38% were caused by Staphylococcus aureus. Nasal S. aureus colonization is associated with increased SSI risk and preoperative nasal decolonization decreases S. aureus SSI risk. Historically, our institution recommended a five-day course of nasal mupirocin decolonization prior to selected high-risk procedure types, though this process it not possible for urgent cases and outpatient compliance is low. Nasal povidone iodine (PI) is a topical antiseptic used commonly in adults as an alternative to nasal mupirocin for S. aureus decolonization and SSI prevention. This practice is less commonly described in pediatric patients. Methods: In addition to standard SSI prevention measures, universal nasal PI application was implemented preoperatively (as a single topical application following induction of anesthesia) in July 2024 for patients ≥34 weeks corrected gestational age (CGA) undergoing the following high-risk surgical procedures: ventricular shunts, spinal fusions, and all cardiothoracic (CT) procedures. Compliance with nasal PI application was monitored based on documentation in the electronic medical record. Mean monthly total SSI rates (per 100 procedures) and mean monthly S. aureus SSI rates for these procedure types were followed pre- and post-implementation of universal nasal PI and compared via unpaired t-test. Results: Documented compliance with nasal PI application was 51% overall, ranging from 22% for ventricular shunts to 75% for CT procedures. Implementation of universal nasal PI preoperatively was associated with a non-statistically significant decrease in composite mean SSI rates (Figure 1A): 3.5 per 100 procedures pre-implementation, 2.3 post-implementation (p=0.52). A statistically significant decrease in composite mean S. aureus SSI rates was observed (Figure 1B): 1.3 per 100 procedures pre-implementation, 0.0 post-implementation (p=0.02). Conclusion: Despite modest documented compliance, implementation of a universal preoperative nasal PI program, in conjunction with standard SSI prevention measures, was associated with decreased S. aureus SSI rates in pediatric patients undergoing high-risk surgical procedures.

Figure 1. Total (1A) and Staphylococcus aureus (1B) surgical site infection (SSI) rate per 100 ventricular shunt, spinal fusion, and cardiothoracic procedures (combined) by month from January 2023 through November 2024. The solid vertical line indicates the beginning of the period with increased S. aureus SSI rates (pre-implementation period). The dashed vertical line indicates the start of the implementation period. Mean SSI rates for the pre- and post-implementation periods are indicated by the horizontal lines and compared via t-test.

Background: Daptomycin-nonsusceptible Enterococcus faecium (DNS E. faecium) is an emerging multidrug-resistant pathogen associated with poor clinical outcomes. Prompted by an increase in DNS E. faecium at our institution in 2023 (Figure 1), we sought to characterize patient characteristics and generate hypotheses about potential risk factors. Methods: We conducted a retrospective case series of 75 patients with confirmed DNS E. faecium (MIC ≥6) across 10 hospitals (served by a single Microbiology laboratory) within the University of Maryland Medical System between January 1, 2023, and November 30, 2024. Data collected included demographics (age, gender, race, ethnicity), clinical history (prior Enterococcus or VRE infections, immunosuppression), infection characteristics (site, Healthcare-associated (defined as onset >48 hours from admission) vs. Community-onset), and antibiotic exposure (vancomycin, daptomycin, linezolid, rifaximin) within 90 days. Immunosuppression was defined as corticosteroid use (≥10 mg prednisone for ≥5 days), chemotherapy, transplant, neutropenia (ANC < 1 500), or other immunosuppressive conditions. Patients with repeated infections were included once, for their first episode. Results: An increase in the incidence of DNS E. faecium was observed at our healthcare system starting in August 2023 (Figure 1). Of 75 patients, 55% were male, 52% were White, 33% were Black, with 92% identifying as non-Hispanic. The mean age was 65 years. A total of 57% of infections were healthcare-associated, with 27% occurring in ICU settings. Specimen sources included blood (20%), urine (5%), and abdominal (48%). Only 5 cases (7%) were considered colonization, while 10 cases (13%) with bacteremia had an ongoing intra-abdominal process. Prior antibiotic exposure was documented in 84% of cases, including vancomycin (51%), daptomycin (15%, high-dose (8-12 mg/kg daily) in 9% of cases), linezolid (13%), and rifaximin (5%). Immunosuppression was present in 39% of patients, and 72% had underlying gastrointestinal pathology (Table 1). Enterococcus was recovered from a previous culture in 20 cases (27%), with 9 (12%) being VRE. Among DNS E. faecium isolates, 59% were vancomycin-resistant, and 48% of those patients had prior vancomycin exposure within the preceding 90 days. Conclusion: Patients with DNS E. faecium frequently exhibit prior antibiotic exposure, immunosuppression, and gastrointestinal pathology. However, significant prior exposure specifically to daptomycin was not found. Approximately 40% of isolates were susceptible to vancomycin; therefore, clinicians need to be alert to the possibility of daptomycin resistance in vancomycin-susceptible E. faecium infections. Further study, including case-control analyses, to identify specific risk factors and clarify the role of prior antibiotics vs transmission in the healthcare setting is needed

Background: The dimorphic fungus Coccidioides is endemic in the Southwestern USA and most commonly causes respiratory infection (“Valley Fever”). While the true community prevalence of this respiratory infection is unknown, experts estimate that 30% of community-acquired pneumonia (CAP) cases in Southern Arizona are due to Coccidioides. We were interested in determining how often patients admitted for CAP are tested for coccidioidomycosis. Methods: We identified patients who were admitted to Banner University Medical Center – Phoenix with community-acquired pneumonia from 1/1/2019-6/30/2024 by the ICD-10 code J18.9. Among this patient population, we determined the percentage tested for coccidioidomycosis (via serological test) and the percentage that tested positive. Regarding management, we elicited whether an infectious diseases consultation occurred during the hospitalization and if treatment included the antifungal fluconazole versus ceftriaxone and Azithromycin. Results: We identified 9,677 patients admitted with an ICD-10 code J18.9 between 1/1/2019 and 06/30/2024. The mean age (SD) was 60.3 (17.2) years and 56.3% were males. 3,536 (36.5%) patients were tested for coccidioidomycosis, and 389/3,536 (11%) had a positive serology. 14.2% of CAP patients were seen by an ID specialist. Among those with coccidioidomycosis, 56.3% (n=219) were seen by an ID specialist. Only a small fraction (n=974, 10.1%) of all CAP patients received fluconazole. Among the 389 with Valley Fever, 52.2% received fluconazole, while almost 70% were given ceftriaxone and/or azithromycin at any point during the admission. Transfer to the ICU, length of stay and hospital mortality were not significantly different in those with detected coccidioidomycosis versus others. Conclusions: In this large observational study in an area endemic for coccidioidomycosis, only 36.5% of those admitted for community-acquired pneumonia were tested for coccidioidomycosis 11% of those who got tested were found to have Valley Fever. Positing a similar coccidioidomycosis prevalence in the remaining 63.5% of CAP patients who were not tested for it, one could extrapolate a total of 676 missed cases based on 11% positive serology rate. To determine the true prevalence of coccidioidomycosis in our region, broader testing should be implemented. Our data also indicate that antifungals are rarely offered for coccidioidal CAP, while unnecessary use of antibacterials for this endemic mycosis is a target for antimicrobial stewardship.