Background: Substance use disorders (SUDs) disproportionately affect pregnant and parenting persons in the United States. Long term residential programs (RTPs) provide comprehensive, structured care that improves pregnancy and neonatal outcomes. However, shared living environments that include young children increase vulnerability to respiratory virus transmission, and evidence to guide infection prevention and control (IPC) in RTPs is limited. In December 2024, an RTP in the northeastern United States housing 13 parenting persons with 15 children experienced an outbreak of respiratory syncytial virus among children, resulting in 14 symptomatic cases, 7 laboratory-confirmed infections, and 5 hospitalizations. This study aimed to identify barriers to and enablers of IPC practices among RTP residents and staff to inform interventions tailored to this unique setting. Methods: In November 2025, we conducted six focus groups at the RTP: three with residents and three with staff. Due to Institutional Review Board restrictions, sessions were not audio-recorded; instead, a trained scribe captured detailed field notes. Data were analyzed using conventional thematic analysis, guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) model. Results: Thirteen of 14 residents and 18 of 25 staff participated. Three overarching themes were identified. First, IPC capability was fragmented. Both residents and staff recognized the role of IPC in reducing respiratory virus transmission. However, residents primarily relied on social media and internet sources for information, while staff relied on guidance from healthcare professionals. Misunderstanding and absence of standardized, facility-level IPC policies led to confusion regarding appropriate cleaning/disinfecting practices and adherence to isolation/quarantine criteria. Second, IPC opportunity was constrained by contextual and structural barriers. Residents entered the program from diverse living situations, resulting in divergent interpretations of IPC norms, including hand hygiene and environmental cleaning. Shared spaces, reliance on resident-performed cleaning without consistent supervision or accountability, lack of commercial cleaning services, and inconsistent enforcement of cleaning and isolation procedures limited effective IPC implementation. Third, IPC motivations were misaligned. Staff viewed IPC practices as opportunities for life-skills development, whereas residents often perceived cleaning and isolation measures as stigmatizing or punitive, negatively affecting symptom disclosure and IPC practice adherence. Conclusions: Although IPC practices in RTPs aim to prevent illness among residents and children, implementation is hindered by knowledge gaps, structural constraints, perceived stigma, and misaligned motivations. These findings underscore the need for clear, standardized policies and trauma-informed, public health–focused IPC strategies. IPC professional societies are well positioned to develop context-specific guidance for this understudied residential setting.

Wing shape is integrally related to flight performance and function in extant animals. Analyzing this relationship in pterosaurs is complicated by the fragmentary nature of the fossil record and because the flight dimensions of wing membranes do not preserve. In the absence of fully extended pterosaur wing fossils, scientific reconstruction of the pterosaur Bauplan presents the clearest alternative for analysis. However, these wing shapes are subject to multiple conflicting scientific opinions and the artistic styles of the researchers and illustrators reconstructing them. Here we test the functional ramifications of different wing-shape reconstructions. We use theoretical morphospace analysis to establish whether modern reconstructions of pterosaur wings exhibit the diversification and functional performance expected of living animals. Pterosaur wing reconstructions show little by way of taxonomic separation either in shapespace or functional performance, with all pterosaur groups overlapping independent of time, size or proposed niche. This suggests that published pterosaur reconstructions underestimate the diversity of wing shapes expected of such a diverse group and are not reflective of flying animals. Stylistic approaches have little effect on the occupation and diversity of pterosaur reconstructions, suggesting that the underpinning issues lie in the lack of scientific consensus on the shape and structure of the wings, rather than how they are reconstructed.

Background: Environmental hygiene (EH) plays a critical role in reducing healthcare-associated infection (HAI) risk, yet significant variability persists in hospital patient room cleaning and disinfection. While discharge cleaning compliance is frequently studied, real-world practices during daily occupied patient room cleaning remain poorly characterized. Furthermore, the time to complete Environmental Services (EVS) tasks is rarely reported in published literature, despite being linked to budget, facility throughput, and patient and employee satisfaction. Researchers conducted a multi-hospital, observational study about environmental cleaning processes. Methods: Across 3 large (<500 beds) teaching hospitals in 3 distinct US regions, researchers shadowed EVS technicians during daily and discharge patient room cleaning across diverse ward types. Direct practice observations documented total turnover time, time to complete tasks such as cleaning the patient and bathroom room surfaces, floor mopping and non-disinfection tasks using a standardized data collection tool (Figure 1). Cleaning compliance was also measured via visual assessment, defined as wiping a surface with a disinfectant wipe or cloth. Results: A total of 638 daily and 91 discharge cleans were evaluated. The average occupied daily room turnover time was 9 minutes. However, square footage, isolation needs, in-room equipment and EVS expectations varied across unit types and individual facilities. For daily occupied room cleaning, on average, more time was spent on non-disinfection tasks like removing waste, refilling consumables and patient engagement (see Table 1). High-touch surface (HTS) cleaning compliance during daily cleans was low (38–48%), whereas floor mopping occurred in <90% of rooms. Site Z spent approximately twice the average time performing a daily room clean compared to Sites X and Y, however, did not achieve greater than 50% HTS cleaning compliance. Discharge cleaning demonstrated markedly higher HTS compliance (87–92%) and longer average duration (Table 2). Conclusion: To date, EH research has been focused on cleaning compliance measured by fluorescent marking, ATP swabbing and/or environmental culturing. Less research, however, is available regarding daily occupied patient room cleaning and the time and resources needed to do it successfully. Our research revealed that EVS technicians across 3 large hospitals spent an average of 9 minutes on daily room cleaning and only a third of that time spent using a disinfectant. Many healthcare disinfectants used by EVS have a contact time of 5 minutes or more. Healthcare leadership should have realistic expectations of what can be accomplished in budgeted cleaning time and the impact of time on disinfectant efficacy, regulatory compliance and infection prevention.

Background: Central line-associated bloodstream infections (CLABSIs) remain a significant source of preventable harm in hospitalized patients, often resulting from missed dressing changes and mislabeled tubing. Research indicates that most CLABSIs occur more than five days after catheter insertion, highlighting the importance of maintenance practices. This project, conducted at Atrium Health Union/Union West, aimed to reduce CLABSI rates by improving adherence to central line care protocols through innovative use of secure chat photography. Methods: Using the Plan-Do-Study-Act (PDSA) framework, the team identified procedural gaps in dressing changes and tubing labeling. A novel intervention was implemented: frontline nurses sent secure chat photos of central line dressings and tubing labels to leadership at each shift change via the electronic medical record (EMR). This real-time visual verification system enhanced compliance monitoring and accountability. Stakeholder engagement was prioritized through shared governance, pilot testing, and feedback loops. Pre- and post-intervention audits measured compliance, and statistical analysis validated the impact. Results: Pre-intervention compliance with central line maintenance protocols was 83%. Post-intervention, compliance improved to a range of 92.4% to 100% across seven units, averaging 95.5% with sustained results for a year thus far. This improvement correlated with a reduction in CLABSI rates, contributing to better patient outcomes and potential cost savings, as each CLABSI can cost between $16,000 and $45,000. The project is on track to meet its goal of ≥99% compliance, supported by ongoing audits, leadership feedback, and integration of the secure photo process into standard workflows. Conclusion: This initiative successfully leveraged digital tools to address a persistent clinical challenge. Secure photo documentation via EMR messaging proved to be an effective, scalable, and low-cost strategy for improving central line care compliance. The intervention not only enhanced patient safety and reduced infection risk but also promoted health equity by standardizing care across units. Its replicability across other healthcare settings makes it a valuable model for broader dissemination. The project demonstrates how technology-driven solutions can transform infection prevention practices and support institutional goals of safety, quality, and equity in care delivery.

Background: Almost a decade has passed since the inaugural Core Elements of Outpatient Antibiotic Stewardship from the Centers for Disease Control and Prevention. Recognizing that outpatient prescribing accounts for upwards to 90% of antibiotic use, with 30% of those prescriptions deemed inappropriate, four core elements (commitment, action, tracking, education) guide the identification and monitoring of stewardship activities. We aimed to examine infection preventionist (IP) perceptions of outpatient stewardship programs. Methods: Members and non-members of the Association for Professionals in Infection Prevention (APIC) were invited to participate in the quinquennial electronic survey of IPs between June 6 and July 31, 2025, through email, QR codes, and social media campaigns. Data were collected on nine outpatient antimicrobial stewardship program (ASP) characteristics, including structure, leadership, and educational resources. Descriptive statistics were used to summarize the data. Result: Responses were received from 199 IPs who selected outpatient settings as their primary work location. Among these, 58% (n=115) reported the presence of an ASP, while 10% (n=19) were unsure. IPs reported that most ASPs were led by either clinical pharmacists (38.5%, n=37), infectious disease physicians (24%, n=23), or infectious disease pharmacists (19%, n=18), although 13% of IPs (n=15) could not identify the program leader. Nearly one-quarter of respondents (27%) indicated that they had access to an infectious diseases pharmacist. Over 75% (79%, n=86) reported the use of up-to-date treatment recommendations for infections; however, 24.8% (n=27) were unsure whether education on appropriate antibiotic prescribing was offered. Participation in multidisciplinary ASP rounding was evenly divided: yes (31%, n=34); no (35.8%, n=39); and do not know (33%, n=36). Over a third (35.3%) of IPs attended rounds. Conclusion: Although most outpatient stewardship programs are led by frontline clinical pharmacists, this survey found they were frequently supported by infectious diseases experts. This likely reflects the perception that these programs operate in hospital systems where IPs are present. Surprisingly, multidisciplinary rounding was reported even in outpatient environments, challenging assumptions that such practices are limited to inpatient stewardship. While education is a core component of stewardship, multidisciplinary educational efforts are necessary to make resources more visible and accessible across disciplines.

Background: Antibiotic allergies are frequently reported in children, yet most reactions are mild and should not preclude first-line therapy. Inaccurate allergy labels contribute to increased healthcare costs, Clostridioides difficile infection, and suboptimal or unnecessary antibiotic use. We aimed to characterize the incidence and features of inpatient antibiotic-associated allergic reactions, including serious events, and to determine the proportion of antibiotic regimens that were inappropriately modified in response to reported allergies. Methods: We conducted a retrospective study of patients ≤18 years admitted to Severance Children’s Hospital (Republic of Korea) during 2022–2024 who received oral or intravenous antibacterials and had an antibiotic-related adverse drug reaction (ADR) documented as “allergy” in the electronic health record. ADRs to antiviral, antifungal, or antiparasitic agents and reactions occurring in outpatient or emergency settings were excluded. Each discrete sign or symptom attributed to an antibiotic was counted as one allergic-reaction event. Management was considered appropriate if first-line therapy was continued for mild reactions, discontinued when unnecessary, aligned with international or national guidelines, or reflected pediatric infectious diseases expert opinion. Results: Among 31,164 admissions, 17,614 (56.0%) patients received antibiotics. A total of 215 antibiotic-related ADRs (0.92%) were documented, including 161 allergic-reaction events in 122 patients (0.7%) associated with 143 antibiotic prescriptions. Males accounted for 59.0% of cases; median age was 7.8 years (IQR, 2.8–12.4). The most common indications were surgical prophylaxis (34.3%), systemic febrile illness (14.0%), and pneumonia (11.2%). Frequent manifestations included nausea/vomiting (32.3%), urticaria (23.6%), and non-urticarial rash (18.1%). ?-lactams accounted for 67.3% of implicated agents; the most frequent drugs were ceftriaxone (26.8%), vancomycin (15.7%), and ampicillin/sulbactam (5.9%). Anaphylaxis occurred in 6 patients (5.0% of reactions; 0.002% of antibiotic prescriptions). Overall, 28.7% of allergy-labeled reactions were managed inappropriately, and 8.4% resulted in unnecessary escalation to broader-spectrum antibiotics (Table 1). Surgical prophylaxis was associated with reduced odds of inappropriate management compared with therapeutic use (OR, 0.46; 95% CI, 0.22–0.99; P Conclusion: True antibiotic allergy in hospitalized children is uncommon, yet nearly one third of reported allergies led to suboptimal or inappropriate antibiotic use. With the recent launch of the national antimicrobial stewardship pilot program in Korea (November 2024), we plan to develop an evidence-based clinical pathway for antibiotic allergy management and incorporate de-labeling strategies into the hospital electronic system to optimize antibiotic selection.

Background: Previous studies have shown that unnecessary antibiotic use is common in outpatient settings, particularly for acute respiratory illnesses. We assessed changes in outpatient antibiotic prescribing and estimated the proportion of unnecessary prescribing to identify additional opportunities for improvement and evaluate progress toward national goals to improve antibiotic use. Methods: We used Merative MarketScan commercial claims (patients aged 0-19 and 20-64 years) and Centers for Medicare & Medicaid Services (CMS) Medicare carrier claims and Part D event files (patients aged ?65 years) to identify enrollees with medical and prescription drug coverage for 2019 and 2023. Enrollees were weighted by months of enrollment. Using ICD-10 codes, outpatient encounters were assigned to a single diagnosis using a tiered algorithm based on the most likely indication for antibiotics. Tier 1 included diagnoses for which antibiotics are indicated (e.g., pneumonia, urinary tract infection); tier 2 included diagnoses for which antibiotics are sometimes indicated (e.g., sinusitis, pharyngitis, suppurative otitis media); and tier 3 included diagnoses for which antibiotics are not indicated (e.g., bronchitis, viral upper respiratory infection). Oral antibiotics dispensed on the visit date or within 7 days afterward were linked to the encounters. We calculated the proportion and rate (per 100 patient-years) of antibiotic-associated encounters by tier and age group and reported percent change from 2019 compared to 2023. Results: The proportion of adult outpatient encounters resulting in an antibiotic prescription was lower in 2023 compared to 2019 across diagnostic tiers (Figure 1). The largest reduction occurred for tier 3 conditions, where antibiotic-associated encounters decreased by 32% among adults aged ?65 years and by 30% among adults aged 20-64 years. Tier 3 prescribing was highest for adults aged ?65 years. In 2023, the highest antibiotic prescribing rates were for tier 2 conditions, particularly among children aged 0-19 years (77 antibiotics/100 patient-years) and adults aged 20-64 years (43 antibiotics/100 patient-years) (Figure 2). Conclusions: Using nationally representative data, we found that adults had fewer healthcare visits associated with antibiotic prescriptions in 2023 compared with 2019, with the largest declines occurring for conditions for which antibiotics are unnecessary. However, there are still opportunities to reduce unnecessary antibiotic prescriptions, especially for older adults. Antibiotic stewardship efforts should also focus on conditions for which antibiotics are sometimes indicated (e.g., sinusitis). This includes assessing diagnosis-specific criteria for prescribing an antibiotic and evaluating antibiotic selection and duration to benchmark appropriateness and tailor improvement efforts.

Background At University of Washington Medical Center (UWMC), patients undergoing evaluation for extrapulmonary tuberculosis (EPTB) are routinely placed in airborne precautions and undergo pulmonary tuberculosis (PTB) rule-out, regardless of epidemiologic risk factors or pulmonary symptoms. This approach was implemented to support early identification of occult PTB in asymptomatic individuals. While prior small studies suggest PTB may occur infrequently among patients with EPTB without pulmonary symptoms, CDC guidance recommends PTB evaluation based on clinical suspicion and epidemiologic risk. The clinical yield and operational, financial, and environmental impacts of UWMC’s universal approach are unclear; this study characterizes its utility and burden. Methods We conducted a retrospective descriptive analysis of adult patients evaluated for EPTB at a low TB-incidence tertiary-care academic medical center (April 2024–December 2025). Data were exempt from IRB review. Outcomes included patient characteristics (including hematology-oncology status), diagnostic testing, TB identification, airborne precaution duration, and costs. EPTB evaluation was defined by initiation of the institutional pathway (e.g., airborne precautions and PTB rule-out orders). Laboratory and PPE costs were estimated using institutional unit costs. PPE utilization was estimated using a workflow-based assumption of 14 room entries per day. Sensitivity analyses used 10 and 18 daily room entry assumptions. Environmental impact was assessed descriptively via estimated PPE encounters. Results Thirty-eight patients undergoing evaluation for EPTB were included (133 airborne precaution days). Twenty-five (65%) had no identified epidemiologic TB risk factors; many had nonspecific pulmonary findings. Two (5%) had hematologic malignancies. Estimated laboratory cost was $4,640.38 ($122.12/patient). Estimated PPE cost was $2,197.16 ($57.82/patient), with sensitivity estimates ranging from $1,510–$2,719. The combined estimated direct cost was $6,837.54 ($179.94/patient). Under base-case assumptions, airborne precautions generated 1,862 PPE encounters. Among this 38-patient EPTB evaluation cohort, 1 case of EPTB and 0 cases of PTB were identified. Conclusions In this cohort, routine PTB rule-out and airborne precautions were applied during evaluation for possible EPTB, yet no patients were diagnosed with PTB. Although direct laboratory and PPE costs were modest, this practice generated substantial airborne precaution days and imposed unmeasured burdens, including delays in care/procedures, reduced quality of care, and additional staff/provider time. Environmental impacts beyond estimated PPE utilization were not captured. These findings suggest the current universal approach overestimates risk in this population. A targeted, risk-stratified approach aligned with epidemiologic risk, clinical suspicion, and guideline-based recommendations may reduce unnecessary precautions and testing while maintaining patient and staff safety.

Background: Antibiotic-resistant gram-negative (RGN) bacteria pose a significant threat to child health, leading to use of contact precautions to limit nosocomial transmission. While adult data increasingly support selective discontinuation of precautions, pediatric-specific guidance remains limited due to uncertainty around the duration of RGN colonization. Based on institutional expert opinion, on November 19th, 2021, our institution implemented a policy allowing removal of contact precautions after one year for patients without subsequent RGN culture positivity. This study aimed to characterize RGN carriage duration, identify risk factors for prolonged carriage, and evaluate the impact of the policy change on hospital-associated RGN incidence. Methods: We conducted a retrospective chart review of patients ages 0-21 years with identified RGNs in the hospital electronic medical record system from May 2021 to November 2025. RGNs of interest included extended-spectrum-beta-lactamase (ESBL) Enterobacteriaceae along with multidrug-resistant (MDR) Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter species. Patients with carbapenem-resistant isolates or cystic fibrosis were excluded based on ineligibility for removal of precautions. Data extraction focused on each patient’s first documented RGN infection during the queried timeframe including organism, resistance pattern, and specimen source. Additional evaluation included whether the isolate was treated as an active infection, subsequent positivity with any RGN isolate, and potential risk factors for recurrent RGN positivity. Categorical exposure variables were assessed via ?² test of association and Wilcox ranked sum test to determine differences in duration of RGN carriage (R v4.5.1). Results: We identified 232 patients with RGN isolates. Of these, 158 met inclusion criteria with most exclusions (53/232) due to carbapenem-resistance in the initial RGN isolate. Most patients (91/158, 57.6%) did not have subsequent positivity with any RGN. Of those with durable carriage of the same RGN species (49/158, 31.0%) the median was 269 days (range 39 – 1463). Only presence of underlying genitourinary complexity was associated with risk of subsequent positivity with the same RGN (?² = 10.045, p = 0.001527) and prolonged median duration of RGN carriage of 396 days (Wilcox ranked sum test of identical distributions, W = 428, p = 0.01004). When comparing the seven months leading up to and following the policy change implementation period, there was no increase in incident hospital-associated RGN infections per 100,000 inpatient days. Conclusions Current hospital epidemiology supports a policy of removal of contact precautions after one year of no further RGN positivity and may serve to inform broader pediatric policy decisions.

Background: Surgical site infections (SSIs) following colorectal surgery are associated with increased morbidity, mortality, length of stay, and costs. During our hospital’s fiscal year (FY) 2024 reporting period (8/2023–7/2024), we had15 colorectal SSIs with a standardized infection ratio (SIR) of 2.43, indicating a need for focused improvement. Methods: In August 2024, we convened a multidisciplinary team in our 600-bed academic hospital, including perioperative nursing and education, infection prevention, anesthesia, colorectal surgery, infectious diseases, hospital epidemiology, quality and patient safety. After a gap analysis, the team implemented evidence-based interventions (Figure 1) guided by the Lean Six Sigma framework—Define, Measure, Analyze, Improve, and Control. The interventions included: 1) initiating apparent cause analysis (ACA) reviews for all colorectal SSIs with a multidisciplinary team; 2) standardizing colorectal surgery practices with wound protectors and a protocolized closing bundle (i.e. glove/gown change and closing tray); 3) creation of a perioperative antibiotic prophylaxis quick reference guide; and 4) clinical documentation improvement strategies for infections present at time of surgery (PATOS). We compared process measures (adherence to closing bundle, wound protector, and perioperative antibiotics) and outcome measures (number of SSI and SIR) between FY2024, FY2025 (8/2024-7/2025) and FY2026 (8/2025-10/2025). A run chart and Power BI were used for data visualization and metrics were reviewed monthly with the working group. A statistical process control (SPC) XmR chart was constructed retrospectively to assess process stability and detect special cause variation after the implementation of initiatives. Results: Compared to FY2024, we had fewer colorectal SSIs (15 vs 5) and a lower SIR (2.43 (95% confidence interval [CI] 1.41–3.91) vs 0.82 (95% CI 0.30-1.83) in FY2025 (Table 1). In the first quarter FY2026 we had two colorectal SSIs. Compared to FY2024, we observed increased adherence with the closing bundle (21%), wound protector use (13%), and perioperative antibiotics (4%) with continued increases in FY2026 (Table 1). Over time, early special cause variation was followed by stabilization with a centerline shift in SIR from 3.21 to 1.40 and upper control limit (UCL) reduction from 10.50 to 4.59 following implementation of quality improvement interventions (Figure 2). Conclusion: Iterative and continual process improvement with a multidisciplinary, engaged team significantly reduced colorectal SSIs at our hospital and improved compliance with key infection prevention measures. Ongoing efforts are focused on continued implementation of our key initiatives and sustainment.

Background: As part of the Centers for Disease Control and Prevention’s (CDC’s) Emerging Infections Program (EIP), the Tennessee Department of Health (TDH) conducts surveillance on Clostridioides difficile infection (CDI) in a designated catchment area. As part of ongoing surveillance, select TDH staff have access to Centers for Medicare and Medicaid Services (CMS) patient-level data under a CDC-CMS data use agreement. The aim of this study was to assess the alignment between the most prevalent chronic conditions among CDI cases reported through EIP and those reported through CMS. Methods: We matched patients who were 65 years and older from 2022 EIP data with Medicare beneficiaries on date of birth, sex, county of residence, and ZIP code, and retained unique matches for our study. Comorbidities present in both the CMS 30 CCW Chronic Conditions list and in the CDI case report form were included. The most prevalent chronic conditions in each dataset were identified. We employed Cohen's Kappa to assess inter-rater reliability between chronic conditions reported through EIP chart abstractions and those reported via CMS claim submissions. A Cohen’s Kappa greater than 0.4 indicates moderate or greater inter-rater reliability. Analysis was conducted using SAS Studio. Results: Of the 431 EIP CDI patients in 2022, 196 patients were 65 years or older and eligible for inclusion. 130 of these patients matched uniquely to a Medicare beneficiary ID on the demographics listed above (66.3%). The most prevalent chronic conditions identified among CDI patients were cardiovascular disease (CVD) (n=31), diabetes mellitus (n=26), chronic kidney disease (CKD) (n=21), and chronic pulmonary disease (CPD) (n=14). Diabetes mellitus diagnoses between the two datasets had the highest concordance with a Cohen’s Kappa of 0.5226 (p<0.0001), followed by CKD at 0.3984 (p<0.0001), CPD at 0.2313 (p=0.0081), and CVD at 0.1371 (p=0.1162). Conclusions: Only diabetes mellitus diagnoses showed moderate concordance between EIP and CMS datasets. EIP processes utilize chart review to generate surveillance data, which is person-power intensive. This limited study indicates that comorbidity data for CDI patients may not be completely captured if surveillance was conducted through secondary analyses using CMS data rather than complete chart review by trained public health staff.