This manuscript highlights the voices of Bundjalung elders in northeastern New South Wales, focusing on the impacts of colonization, such as the continued (un)raveling of cultural practices. The authors explore how colonialism perpetuates the exclusion of Indigenous worldviews and knowledge. Nonetheless, Indigenous peoples continue to strongly demand and advocate for meaningful recognition and protection of their cultural property and heritage, rooted in their own systems of law and lore. Through a project embedded in the Bundjalung nation, they examine the value of “cultural property and rights and question whether culture can be governed or regulated. The “Stories behind the fishing net: Sitting with the aunties” initiative at Gnibi College, Southern Cross University, recorded oral histories and traditional net-weaving techniques, fostering community connection and cultural governance. The project highlighted the important roles that cultural practice and objects play in building community and culture between and among Indigenous clans within the Bunjalung nation.

Background: Vascular access devices (VAD), including central venous catheters (CVC) and peripheral intravenous catheters (PIVC), are among the most common medical intervention for hospitalized patients, yet they are also a major source of infectious and noninfectious complications. The Centers for Disease Control and Prevention (CDC) recommends prompt removal of CVC that are no longer indicated as a cornerstone of CLABSI prevention, although cessation of CVC indication is ill-defined. Our hospital implemented a Device Stewardship program to identify VAD that were likely inappropriate and to nudge providers to remove them promptly. The objective of this study is to quantify the opportunities to decrease VAD utilization and to describe early Device Stewardship efforts. Methods Study design and population. This is a retrospective cohort study at a 500-bed academic safety net hospital in Denver, CO. All inpatients hospitalized between 10/1/2025 and 12/31/2025, were eligible for inclusion. CVC placed for ECMO or rapid rewarming were excluded. Definitions. The following VAD were generally considered unnecessary: Femoral triple lumen catheters (TLC) in place for <1 day TLC present in a patient on an acute care unit Duplicate VAD (peripherally-inserted central catheter [PICC] and PIVC) in a patient on an acute care unit Intervention. Infection preventionists (IPs) identified eligible patients through an Epic worklist. Standardized text messages were used to suggest de-escalation of VAD to nursing and provider teams on weekdays (Figure 1). Results There were 576 TLC device days and 871 PICC device days in hospitalized inpatients during the study period. VAD selection could be improved in 29.6% of these patients (Table 1). Duplicate VAD was identified as the most frequent opportunity for improvement whereas femoral TLC present for <1 day was the least frequent opportunity. IPs contacted the clinical teams of 64 unique patients with duplicate VAD to suggest removal of ≥1 PIVC; 36 PIVC in 25 patients (39%) were removed as a result of intervention. Additionally, 5 femoral TLC present for <1 day and 15 TLC on acute care units were intervened upon with 1 femoral line and 3 TLC (20% each) removed during the study period. Conclusion Despite national guidelines to remove unnecessary VAD, there is ample opportunity to deescalate VAD in clinical practice. Simple criteria can be developed to standardize the selection and to prompt earlier removal of VAD, particularly duplicate access. Work can be done to improve the acceptance rate of suggestions.

Introduction Urinary tract infections (UTIs) are among the most common infectious diseases and rank as the second most prevalent infection worldwide. Objectives This study aimed to identify the species-specific distribution of pathogens in positive UTI cultures from both hospitalized and ambulatory patients and to evaluate the applicability of current UTI treatment guidelines in patients from Silesia, southern Poland. Patients and Methods In this retrospective, multicenter study, 85,485 urine samples collected in Poland between 2022 and 2023 were analyzed. Samples were obtained from inpatients (n = 52,294) and outpatients (n = 33,191) with suspected UTIs. Participants were categorized into three groups: premenopausal women, postmenopausal women, and men. Antibiotics were classified using the WHO AWaRe (Access, Watch, Reserve) framework. Results Overall, antibiotic susceptibility was low. The estimated risk of ineffectiveness of empirically prescribed therapies ranged from 26.7% to 44.6%, depending on whether patients were treated as inpatients or outpatients. Among inpatients, Escherichia coli showed 73% susceptibility to co-trimoxazole and ?86.9% susceptibility to cephalosporins only in premenopausal women, compared with approximately 76.6% in men and postmenopausal women. Klebsiella pneumoniae demonstrated susceptibility exceeding 80% only to cefoperazone/sulbactam (86.3%), while susceptibility to other agents remained below 60%. In outpatients, E. coli isolates were highly susceptible to nitrofurantoin (91.9%); however, most other Access-group antibiotics showed susceptibility rates below 60%, except gentamicin (92%). Resistance mechanisms were common: extended-spectrum ?-lactamase production was detected in 12.8% of outpatient and 32.9% of inpatient Enterobacterales isolates, while high-level aminoglycoside resistance was observed in 56.5% of inpatient Enterococcus faecalis and 63.7% of Enterococcus faecium. Conclusion Given the substantial risk of empirical treatment failure under current guidelines, their alignment with real-world clinical practice should be reassessed using more extensive and locally derived epidemiological data.

Background:?The incidence of Candidozyma auris (C. auris) is growing in healthcare settings internationally. International healthcare exposure, compromised skin integrity, lengthy intensive care unit stays all increase risk of C. auris colonization. In Massachusetts, clusters and outbreaks related to C. auris have mostly been characterized by transmission in long term care settings. Over the course of 1.5 years, our institution experienced a cluster of C. auris cases initially hypothesized to be linked to one long stay index patient. Method:?At our tertiary academic medical center, one long stay patient with international healthcare exposure developed a hospital-onset C. auris bloodstream infection. In accordance with public health guidance, any time a clinical isolate is identified, point prevalence screening (PPS) is conducted on impacted unit(s). When possible, we also attempted to proactively screen patients with known recent international healthcare exposure for C. auris, though this was not implemented systematically. Given the protracted nature of our cluster and significant overlap in inpatient spaces and time of several patients, we used Nanopore and Illumina genomic sequencing to identify chains of transmission and to inform infection prevention related interventions. Result:?Over the course of the we identified clinical isolates, positive PPS isolates, and positive screening isolates for patients with international healthcare exposure, for a total of 19 isolates. Of these 19 isolates, genomic sequencing was performed on 15 isolates. Genomic analysis revealed three separate introductions of C. auris into our facility, representing subclades Ib, Ic, and III. The largest cluster involving 1 isolates (7 clinical, 4 PPS) comprised of subclade Ic was related to the long stay index patient. The second cluster involved isolates from subclade Ib and was related to a patient who was screened pro-actively for international healthcare exposure. Conclusion: In healthcare settings where C. auris is an emerging but not yet an endemic threat, genomic sequencing can play a critical role in understanding transmission events. At our institution, discovering multiple introductions of C. auris into our facility was unexpected. Genomic sequencing provided reassurance in our infection control interventions and demonstrated the need for serious consideration of a targeted pro-active screening program.

Background: Hand hygiene is the most important tool for preventing the spread of infections in the healthcare environment. Personal protective equipment (PPE) and nails policy are important additional measures for limiting infectious spread. Our facility typically performs both covert and overt hand hygiene, PPE and nail audits. Compliance rates with hand hygiene and PPE have declined since the COVID-19 pandemic. More information was needed on factors contributing to decreasing compliance rates. Methods An anonymous hybrid electronic and print survey was distributed at annual Infection Prevention fair across a 9-hospital system in Eastern North Carolina from April 2025-November 2025. The survey was conducted via Qualtrics. Results There were 432 total responses, 41% were registered nurses, 7% radiation technologists, 6% nursing assistants and 3% or less of a wide variety of other specialties/departments. Community hospitals represented 83% of responses and 17% were from a large academic medical center. Overall self-reported hand hygiene and PPE compliance was 96.10% and 94.3% whereas perceived compliance of peers was 89.29% and 88.7% respectively. Individual unit audits reported a rate of 89.9% hand hygiene compliance during this time period. When asked about specific scenarios, 84.6% of healthcare workers stated they would wear PPE for isolation precautions when entering the room, but patient contact was not anticipated. Conclusions Healthcare workers report high levels of compliance with hand hygiene and PPE but report lower numbers for perceived compliance of peers. In our health system opportunities to improve isolation precaution compliance include increasing availability of PPE and education on need for PPE even when patient contact is not anticipated. There is strong support for a natural nails policy among healthcare workers in our system, but among the minority that were opposed many left comments expressing strong opposition.

Background: Hospital onset bacteremia and fungemia (HOB) is under development as a Center for Disease Control and Prevention (CDC) automated digital quality measure. We evaluated the use of generative artificial intelligence (GenAI) in assessing attribution and preventability of HOB. Methods This is a retrospective cohort study of hospitalized patients with positive blood cultures at 11 US Veterans Affairs (VA) hospitals. We included a random sample of positive blood cultures collected after day 3 of admission where admission date is day 1. GenAI (OpenAI GPT-4o) was prompted to provide the most likely source and adjudicate the preventability of HOB using standardized prompts and clinical data (GenAI). IP experts used GenAI output to provide GenAI-assisted determinations of source and preventability of HOB (IP-AI). HOB event preventability was rated by IP expert using a 6-point Likert scale, responses were combined to 3 categories for analysis. We compared initial GenAI with IP-AI determinations of source and preventability. A separate human-only review by a different IP expert was performed (IP-alone) on a random subset to compare time required for review. Results We included 52 HOB events for IP-AI and a subset of 21 for IP-alone. Enterobacterales were the most common organisms (22/52, 42%) followed by Staphylococcus aureus (9/52, 17%). Median duration to HOB event was 12 (IQR 5 – 31) days. GenAI most commonly attributed bacteremia to gastrointestinal (GI) (14/52, 26.9%), followed by genitourinary (GU) (12/52, 23%), central line (CLABSI) (8/52, 15%), and skin and soft tissue infections (SSTI) (7/52, 14%) sources (Figure 1). IP-AI determination of source agreed with GenAI source in 67% (35/52) of cases. Most agreement between IP-AI and GenAI occurred when HOB was attributed to a bone and joint infection (2/2, 100%), followed by GI source (13/14, 93%), SSTI (5/7, 71%), and GU source (7/12, 58%). Most disagreements (17/52, 33%) occurred when IP-AI attribution was to an unknown source (5/17, 29%) or blood culture contamination (3/17, 18%). GenAI adjudication of preventability matched IP-AI adjudication in 20/52 (39%). The median time to complete an IP-AI review was 11.5 (IQR 6 – 20.5) minutes compared to a median of 25 (IQR 13 – 33) minutes for IP-alone. Conclusion IP experts often agreed with GenAI for source of HOB but disagreed with its preventability. GenAI rarely acknowledged unknown source. Using GenAI for HOB detection is faster than human review but must account for differences in preventability.

Background: Infection prevention and control (IPC) is essential for patient safety across all healthcare settings, yet implementation varies by patient population and care environment. Behavioral health settings present unique and underrecognized IPC challenges related to the care environment and the unique nature of psychiatric care. Patient behaviors and cognitive conditions may hinder adherence, while safety- and therapy-focused features complicate implementation of IPC best practices. Evidence tailored to behavioral healthcare environments remains limited, underscoring the need for contextually appropriate, patient-centered strategies. Method: We conducted a cross-sectional, web-based survey to examine barriers and facilitators influencing implementation of IPC practices in behavioral health settings. The survey was distributed to U.S. and Canadian healthcare organizations participating in the SHEA and APIC Research Networks. Eligible respondents included individuals responsible for IPC programs or institutional policy development. The survey was developed using REDCap and distributed via email through the APIC/SHEA Research Networks over six weeks. Participation was voluntary, anonymous, and uncompensated. Result: A total of 140 respondents completed the survey (response rate: 13%, n=140/1095). Respondents were predominantly hospital epidemiologists (17%, n=21) and infection preventionists (76%, n=96) representing public (34, n=42%), academic/teaching (33, n=41%), non-profit private (25%, n=31), and for-profit private healthcare systems/hospitals (7%, n=9). 81% of respondents reported implementing IPC mitigation plans for outbreaks in the past year, with COVID-19 (76%, n=107), Influenza (52%, n=73), and Norovirus (37%, n=52) being the most cited pathogens. The most identified barriers to IPC implementation/adherence were patient factors (89%, n=124) and environmental constraints (79%, n=111). More than 75% of respondents reported that patient adherence to transmission-based precautions, isolation practices, masking, and hand hygiene were “moderately” or “very” challenging. Participants identified the most effective facilitators to effective IPC in behavioral health settings as IPC protocols tailored to behavioral health, clear outbreak-response guidance specific to behavioral health, and physical space or environmental modifications to better support IPC practices. Conclusion: This study highlights the substantial and distinct barriers to implementing infection prevention and control best practices in behavioral health settings, driven by the unique care environment and patient population. Despite having foundational IPC infrastructure in place, organizations face persistent challenges with practical implementation, including patient adherence to precautions and isolation, as well as environmental and physical design constraints. Our findings underscore the need for context-specific IPC protocols, targeted environmental adaptations, and dedicated IPC expertise to improve patient safety in these often underrecognized healthcare settings.

Ice machines in healthcare environments have increasingly been recognized as potential reservoirs for opportunistic and healthcare-associated pathogens. This study evaluated 43 ice machines across 9 healthcare facilities in the Louisville Metro area during the first half of 2025. Samples were analyzed at a detection limit of 0.1 CFU/mL for key bacterial and fungal organisms associated with hospital-acquired infections. Results revealed no detection of Legionella pneumophila, but notable prevalence of Pseudomonas aeruginosa (4.7%), non-tuberculosis Mycobacteria (NTM) (69.8%), including Mycobacterium chimaera (11.6%), Candida tropicalis (4.7%), Candida glabrata (2.3%), and Acinetobacter baumannii (39.5%), with carbapenem-resistant A. baumannii (CRAB) present in 64.7% of positive A. baumannii sites. Findings highlight substantial environmental contamination in ice machines and reinforce the need for routine monitoring and infection-control strategies. Further, data suggests that healthcare facilities should be aware that more commonly assessed indicator organisms (such as Legionella pneumophila and Pseudomonas aeruginosa) may not provide accurate assessment of the overall microbiological control of these water systems.

Background: Candida auris is an emerging, healthcare?associated pathogen that persists on skin and in the environment. Early identification of colonized patients is central to interrupting transmission, but the optimal screening cadence in cluster settings is uncertain. We evaluated whether intensifying targeted screening and transitioning to in?house PCR were associated with changes in clinical cases at a large quaternary academic medical center. Methods: We conducted a retrospective study from November 2022 through March 2024 in hospital units experiencing C. auris clusters. Screening frequency was escalated in phases—from biweekly to weekly—and later transitioned to in?house PCR to enable faster turnaround and earlier implementation of infection?prevention actions (e.g., isolation/cohorting and enhanced environmental cleaning) per institutional protocol. The primary outcome was the monthly number of new clinical C. auris cases, defined as non?screening clinical isolates with urine and sputum excluded. The secondary outcome was colonization detected by screening PCR or by urine or sputum cultures. Monthly outcomes were monitored with statistical process control (control charts centered on phase?specific means), and effects across phases were summarized as percentage changes versus baseline. Results: Thirty?eight clinical cases were identified; median age was 55 years (IQR 44–65), and 66% were male. Most clinical isolates originated from blood and wound/tissue sources. Fifteen cases (39%) had a prior positive surveillance test; the median time from first positive screen to subsequent clinical isolate was 27 days (IQR 17–120). Monthly clinical cases decreased from 2.5 during biweekly screening to 2.0 with weekly screening (?20%) and to 1.7 after adoption of in?house PCR (additional ?15%; -32% overall vs baseline) (Figure 1). Colonization detections increased when screening frequency changed from biweekly to weekly (5.3 to 13.8 per month; +160%) and then declined after in?house PCR (to 10.2 per month; -26%). These patterns were concordant with control?chart signals at the phase changes. Conclusions: Targeted, more frequent screening coupled with rapid in?house PCR was associated with fewer clinical C. auris cases and with higher detection of colonization, consistent with earlier identification and response. Because the clinical?case metric is less sensitive to testing intensity and speciation practices than colonization counts, it may better capture the impact of hospital interventions on transmission. Findings are limited by the single?center, retrospective design, potential confounding from concurrent infection?prevention measures, and use of monthly counts rather than rates; nonetheless, the phased approach provides actionable evidence to guide surveillance strategies during C. auris clusters.

Introduction: Acinetobacter infections are commonly viewed as hospital-onset events linked to critical illness and invasive devices. We evaluated whether this paradigm holds true at our institution by examining a decade of Acinetobacter infections at an urban safety-net trauma center. Methods: We conducted a retrospective analysis of patients with Acinetobacter spp. isolated from culture at a 500-bed urban academic safety-net Level I trauma center from January 2015 through December 2025. Clinical and epidemiologic variables were abstracted from the electronic health record. Hospital-onset infection was defined as culture collection on or after hospital day 4 (admission day = day 1). Infections not meeting criteria for hospital onset were classified as community-onset and subsequently assessed for healthcare-associated exposures. Healthcare-associated infection was defined by hospitalization, antibiotic exposure, dialysis, or residence in a skilled nursing facility within 60 days prior to diagnosis. Additional covariates included age, sex, birth place, race/ethnicity, intensive care unit (ICU) admission, active chemotherapy or chronic steroid use, chronic lung disease (e.g., chronic obstructive pulmonary disease or COPD), chronic liver disease (cirrhosis or hepatitis B/C), diabetes, substance use disorder (alcohol or illicit drugs), trauma within 90 days, presence of an invasive airway (endotracheal tube or tracheostomy), indwelling urinary or renal catheters, organism identification (A. baumannii vs non-baumannii species), and final antibiotic used for treatment. To identify factors associated with hospital-onset infection, we used multivariable logistic regression with generalized estimating equations (GEE) to account for within-patient clustering from repeated cultures, reporting adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Results: A total of 157 cultures with growth of Acinetobacter spp. were identified during the study period. Acinetobacter baumannii accounted for 69% of isolates. Most cases occurred among inpatients (79%). Hospital-onset infection accounted for 39%, while 61% were community-onset; among community-onset cases, 56% met criteria for healthcare-associated infection. The cohort was predominantly White (45%) or Hispanic (36%). The most common clinical syndromes were ventilator-associated pneumonia (26%), bacteremia (26%), and urinary tract infection (19%). Treatment was administered in 83% of cases, most commonly with levofloxacin (30%) or cefepime (25%). Carbapenem resistance was uncommon (3%). In multivariable GEE analysis accounting for repeated cultures, hospital-onset infection was independently associated with chronic lung disease, recent trauma, and presence of an invasive airway (Figure 2). Conclusions: In this safety-net health system, most Acinetobacter infections were community-onset rather than hospital-onset. Hospital-onset infection was strongly associated with markers of critical illness and lung injury rather than demographic factors.

Background: Older adults (≥65 years) commonly receive antibiotics in emergency departments (ED), where adherence to prescribing guidelines is inconsistent. The extent to which neighborhood disadvantage causally influences these prescribing patterns is unclear. We aimed to estimate the causal effect of community deprivation and vulnerability on guideline-concordant antibiotic selection and to disentangle the relative contributions of overuse and underuse. Methods: We analyzed 1,318,281 ED encounters for 790,562 adults aged ≥ 65 years seen at 119 sites across 15 states (2015–2024). The primary outcome was guideline concordance based on IDSA criteria. Secondary outcomes were overuse and underuse, defined using a three-tier diagnosis framework (tier 1 = antibiotics indicated, tier 2 = sometimes indicated, tier 3 = not indicated). Exposures were census-tract Social Vulnerability Index (SVI) and Social Deprivation Index (SDI). To mitigate confounding and reverse causality, we applied two-stage least squares instrumental-variable models using the maximum state Earned Income Tax Credit as the instrument, adjusting for patient, facility, state, and month-year covariates with patient-clustered robust standard errors. We additionally examined key SVI/SDI components and regional patterns in concordance. Results: Overall concordance was 83.2%; non-concordance comprised 9.5% overuse and 7.2% underuse. Concordance improved from 78.4% (2015) to 83.8% (2024), driven by declining underuse (16.2 to 5.4%) despite rising overuse (5.4 to 10.8%). Antibiotics were given in 80.8% of tier 1, 28.1% of tier 2, and 15.9% of tier 3 encounters. COVID-19 diagnoses accounted for 20.1% of overuse, and urinary-tract infection codes for 33.6% of underuse. The instrument was strong (first-stage F = 348 for SVI; 413 for SDI). In IV models, each 10-point increase in SVI corresponded to a 6.37-point lower concordance (SE 0.69; p < 0.001, Table 1); each 10-point SDI increase, 1.84-point lower (SE 0.20; p < 0.001). Associations were stronger for underuse than for overuse. Lower concordance was linked to longer travel time, higher tract non-employment, household crowding, and lack of vehicle access. Regions of high deprivation and lower concordance clustered predominantly in the South, whereas higher-concordance areas were concentrated in the Midwest (Figure 1). Conclusions: Community disadvantage was associated with lower guideline-concordant antibiotic prescribing for older adults, mainly through increased underuse and modest reductions in overuse. Stewardship programs should monitor both phenomena separately and target high-deprivation areas with enhanced diagnostics, follow-up, and locally tailored implementation to improve equity.

Background: There is increasing awareness of the importance of antimicrobial stewardship in long-term care settings internationally. Despite this, there is little robust surveillance data on the quality of prescribing in this setting to help target interventions. In Australia, nursing homes are known as residential aged care homes (RACHs). The Aged Care National Antimicrobial Prescribing Survey (Aged Care NAPS) is a national, standardized audit program enabling Australian RACHs to monitor antimicrobial use and provide feedback on prescribing practices. Since 2016, the program has collected detailed prescribing data but has not made an explicit assessment on prescribing quality. With revision to Australian national prescribing guidelines, we now have the potential to use this data to assess concordance with guidelines. Methods: All Australian RACHs are eligible and invited annually to participate in the Aged Care NAPS. A single-day point prevalence audit is the primary methodology adopted. Antimicrobial prescribing data are collected by auditors at participating RACHs and entered into an online platform. All residents present on the survey day were included in the audit. Retrospective analysis of Aged Care NAPS data collected between 1 January 2020 and 31 December 2024 was undertaken. Guideline concordance was evaluated for the five most common indications (cystitis, tinea, non-surgical wound infection, pneumonia and cellulitis), using the Therapeutic Guidelines: Antibiotic 16th edition and Dermatology 4th and 5th editions. Results: A total of 41,786 prescriptions from 1,408 RACHs were audited during the study period. The five most common indications accounted for 37.4% of all prescriptions. Incorrect antimicrobial choices were common, such as cefalexin and roxithromycin for pneumonia, and amoxicillin-clavulanic acid and doxycycline for cellulitis. Prevalence of dosing errors ranged from 3.4% (trimethoprim for cystitis) to 78.0% (amoxicillin for pneumonia). Cefalexin was frequently prescribed and commonly incorrectly dosed (70.3% in cystitis, 72.8% in non-surgical wound infections, 68.2% in cellulitis). Over 40% of prescriptions for the top five antimicrobials for each indication exceeded recommended treatment durations, ranging from 41.7% (amoxicillin for cystitis) to 96.8% (ketoconazole for tinea). Prescribing for tinea often exceeded six months and included non-recommended pro re nata (PRN) prescriptions. Conclusion: The Aged Care NAPS shows promise as a tool to monitor the quality of antimicrobial prescribing in long-term care facilities. This analysis has identified targets for improving antimicrobial prescribing, focusing on choice, dosing and duration.

Background: Clostridioides difficile infection (CDI) remains one of the most common healthcare-associated infections and contributes significantly to morbidity, mortality, and healthcare costs. In 2021, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) updated their clinical practice guidelines for CDI treatment, recommending fidaxomicin over vancomycin for both initial and recurrent episodes due to comparable cure rates and a lower risk of recurrence. This recommendation is contingent upon institutional resource availability, as fidaxomicin is currently substantially more expensive than vancomycin. In response to these updated guidelines, a treatment algorithm was developed at UMass Memorial Medical Center (UMMMC) to prioritize fidaxomicin use in patients at high risk for recurrence (Figure 1). This study evaluated the adherence to and clinical outcomes of the institutional CDI treatment algorithm following implementation. Methods This retrospective study evaluated 530 patients admitted to UMMMC with a positive C. difficile PCR test during that admission between January 1, 2024, and June 30, 2025. Of those, 396 met inclusion criteria (Figure 2). The primary outcome was clinical cure, defined as resolution of diarrhea without the need for additional treatment within two days following completion of therapy. Secondary outcomes included 30-day mortality, recurrence at 30 and 90 days, hospital length-of-stay, and treatment-related adverse effects. Statistical analysis was performed using chi-square test for categorical variables, or one-way analysis of variance (ANOVA) for continuous variables, with Bonferroni post-hoc testing in GraphPad Prism. Results No significant differences were observed between treatment groups for the primary outcome of clinical cure (Table 1). Similarly, there were no significant differences in secondary outcomes, including recurrence at 30 and 90 days, or hospital length of stay (Table 1). There was no 30-day mortality documented for any of the groups. No adverse effects associated with vancomycin or fidaxomicin therapy were documented. The majority of treatment decisions were adherent to the institutional algorithm (70.2%) (Table 2). Conclusion Restricting fidaxomicin use to CDI patients at high risk for recurrence appears to be a safe and effective approach. This treatment algorithm provides a practical framework that may be adopted by other institutions to balance cost and efficacy, particularly as the high cost of fidaxomicin remains a barrier for both patients and healthcare systems.

Background: Staphylococcus aureus (SA) colonization affects about 30% of U.S. adults and increases surgical-site infection risk 2 - 10 fold. A prior study by Kline et al. (2018) laid the foundation for evaluating efficacy and cost effectiveness of pre-operative decolonization interventions. This study evaluates an expanded set of up-to-date interventions, including: Strategy 1 - Individuals screening positive for SA receive a 5-day, 3-drug bundle. Non-SA carriers receive 2 pre-operative chlorhexidine gluconate (CHG) showers. Strategy 2 - All individuals receive the 3-drug bundle for 5 days. Strategy 3 - All individuals receive day-of-surgery nasal povidone iodine plus 2 CHG showers. Strategy 4 - All individuals receive day-of-surgery nasal alcohol gel plus 2 CHG showers. The 3-drug bundle consists of daily CHG showers, twice-daily CHG mouth rinse, and twice-daily nasal mupirocin ointment for 5 days leading up to surgery. Methods: A decision analytic model (Figure 1) simulated a U.S. adult population undergoing elective surgery over a 150-day horizon to evaluate the impact of the four strategies on surgical-site infections, SSI-related deaths, and healthcare-associated costs. Model parameters (Table 1) were derived from Kline et al. (2018), supplemental literature, and expert opinion. The model was used to determine SSI cases and costs per 10,000 population. One-way and probabilistic sensitivity analyses were conducted to determine the impact of uncertainty on choice of strategy. Results: Results are summarized in Table 2 and Figure 2. Strategy 2: Treat-all with 3-drug bundle, had the lowest healthcare-associated costs and prevented the most SSI cases, followed successively by Strategies 1, 3 and 4. These findings were robust across a series of one-way sensitivity analysis; the model was most sensitive to SSI probability and the relative risk associated with S. aureus colonization, while treatment efficacy parameters demonstrated limited impact on the overall results. In probabilistic sensitivity analyses, in which multiple parameters were varied, Strategy 2 remained the optimal strategy, whereas Strategy 4 was identified as the most expensive and least effective strategy. Conclusion: The results of this cost effectiveness analysis, combined with the results of our recent survey showing decolonization strategies vary nationally, highlight an opportunity to improve decolonization practices and outcomes.

Background: Beta-D-glucan (BDG) is a blood test that supports invasive fungal infection diagnoses, but is often over-ordered approximately 50% of the time, particularly in low-risk patients or for fungi not associated with BDG production. High rates of inappropriate use and frequent false positives, often driven by certain clinical scenarios or medication interactions, can lead to repeat testing and unnecessary procedures and treatment. While audit-and-feedback interventions can reduce test misuse, they are not feasible or sustainable for most hospitals. We implemented diagnostic stewardship of BDG through a guideline-based order panel with embedded decision support and interruptive alerts to replace a standalone test (figure 1). This quality improvement (QI) study aimed to reduce the use of BDG in the adult inpatient setting by 20% by 3/2026. Methods: From 3/5 -10/25/25, a multi-disciplinary team implemented this QI project at 8 campuses using iterative Plan-Do-Study-Act cycles. The primary outcome was the number of weekly BDG tests ordered across all campuses. Process measures included the number of interruptive alerts, the rate of duplicate tests, and adherence to order panel recommendations regarding appropriate host factors for BDG testing. Data was collected via the electronic health record. Statistical process charts (SPC) were used to display and analyze data, and Associate Process Improvement rules were applied to detect special cause variation. Results: Across the health system, the average weekly serum BDG orders decreased by 17% (figure 2). The false-positive and repeat-test alerts fired on average 76 and 8 times/week, respectively. Due to frequent false-positive alerts, low-impact factors (e.g., piperacillin-tazobactam) were removed, reducing average weekly false positive alerts from 101 in the first half of the intervention to 52. 77% of the false positive alerts were among patients on internal medicine, critical care, and oncology services. Based on chart review of 50 medicine, critical care, and oncology patients, approximately 51% of false-positive OPAs led to successful test interruption (i.e. delayed BDG ordering by ≥6 hours). The percentage of weekly duplicate tests decreased from 23% pre-intervention to 20% during the intervention. Accurate adherence to the order panel in this subset was 76%. Conclusion: In this study, we successfully implemented scalable BDG diagnostic stewardship, achieving a sustained 17% reduction in weekly BDG orders and nearly reaching the 20% target after 32 weeks. Further optimization of OPAs, along with provider feedback and education, may yield additional improvements.

Background: Skin changes can precede central line infections by days to weeks, making early identification essential for prevention. Routine nursing assessments help prevent CLABSIs in hospitals, but comparable surveillance is lacking for patients managing central lines at home, leading to preventable infections and readmissions. Hypothesizing that artificial intelligence (AI) can be trained to reliably detect visible inflammation/infection from a photo, we developed algorithms for auto-detection of early signs of localized skin inflammation or infection. Methods: We conducted a secondary analysis of photos collected from 3 cohorts of adult patients with central venous catheters (CVCs) at a large academic hospital, an outpatient oncology clinic, and 6 nursing homes between January 2014-June 2017. Skin tone was recorded using the Fitzpatrick Scale, as erythema may be harder to detect in darker skin tones (types IV–VI). Insertion-site inflammation or infection was assessed in each photo using the Central Line Insertion Site Assessment (CLISA) score (Table 1) by trained research staff, with two-physician review. A convolutional neural network model was trained de novo from random weights (binary cross-entropy loss) to predict binarized CLISA score, defined as normal/low risk (non-actionable) scores of 0 or 1 vs high risk (actionable) score of 2 or 3. Five-fold cross-validation estimated model performance for accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve receiver operating characteristic (AUC/ROC) with 95% confidence intervals. Results: Among 5,551 photographs of 964 CVCs in 874 adults, there were 1,191 (21%) photos from hospitalized patients, 2,539 (46%) from outpatient oncology patients, and 1,821 (33%) from nursing home residents. Mean (SD) age was 60 (17), 54% were male, and 183 (21%) patients had darker skin tones (Fitzpatrick skin type IV-VI), Table 2. Among all photos, 1,585 (29%) had localized inflammation/infection (CLISA 2 or 3) and 298 (0.1%) had purulence. Compared to gold standard clinician assessment, AI model performance optimized for accuracy was able to distinguish between normal/low risk (CLISA 0-1) and inflamed/infected catheters (CLISA 2 or 3): accuracy 0.82, sensitivity 0.52, specificity 0.94, PPV 0.83, NPV 0.78, AUC 0.87 (95% CI 0.86-0.88); results were similar for models detecting purulence, Figure 1A-B. Conclusion: AI algorithms can identify CVCs with photographic signs of inflammation or infection and signal the need for intervention to prevent CLABSI. AI-autodetection of high-risk catheters can extend hospital CLABSI prevention to settings with limited monitoring, using photographs alone and minimizing reliance on patient self-assessment or care escalation.

Mental health concerns are rising for business school academics who cope with increased expectations about job performance. The multiple and concurrent tasks that academics engage in gives rise to feelings of stress and inadequacy that can lead to mental distress. The changing role of academia has created confusion and as sense of panic surrounding job longevity, which has resulted in increased emphasis on well-being in universities. Whilst universities pride themselves as supposedly good work environments in reality many academics are facing mental health issues. This means the joy once evident in academics in a profession they love has changed due to the increased complexities. In this editorial, I discuss the role mental health plays in an academic’s survival in the global educational environment. The consequences of altering work/life resources are examined with the goal of suggesting ways to alleviate mental health issues whilst respecting the privacy and individualisation of academics.

Background: Proper hand hygiene (HH) is a fundamental practice for reducing healthcare-associated infection transmission and a cornerstone of infection prevention. Dietary technicians, non-clinical food service workers who deliver patient meal trays, routinely move between patient rooms. Although many healthcare institutions have established multimodal HH compliance programs, dietary staff have historically demonstrated lower HH compliance compared with clinical personnel. HH interventions targeting this group remain understudied. We implemented an infection prevention–led HH education class for onboarding dietary staff and evaluated its association with overall dietary HH compliance. Methods: We conducted a quasi-experimental study at a large academic medical center. The onboarding dietary HH class began on March 4, 2024, and was delivered intermittently, averaging twice monthly, with pauses due to operational constraints, through February 28, 2025. Newly hired dietary technicians attended a single in-person, one-hour session during orientation, with no subsequent reinforcement. Instruction was conducted in an empty patient room and emphasized HH upon room entry and exit, appropriate use of alcohol-based hand rub versus soap and water, and correct personal protective equipment use aligned with transmission-based precautions. HH observations for all dietary staff were collected by trained auditors using standardized direct observation protocols. Baseline data were obtained from March 1, 2022, to February 29, 2024, and intervention data from March 1, 2024, to February 28, 2025. Results: Approximately 80 newly hired dietary technicians participated across 21 total classes. Mean HH compliance increased from 80 percent at baseline (95 percent CI, 76.4–84.6; 4,971 observations) to 89 percent during the intervention period (95% CI, 87.2–90.4; 2,932 observations; p < 0.05 by Wilcoxon rank-sum test). Compliance variability decreased, with standard deviation declining from 9.7 percent to 2.3 percent and monthly minimum compliance increasing from 53 percent to 84 percent. In segmented linear regression analysis, HH compliance demonstrated a non-significant upward trend during the pre-intervention period (p = 0.07). Following the intervention, a small but statistically significant downward trend over time was observed (p < 0.01). Conclusions: An onboarding dietary HH education class was associated with higher mean HH compliance and reduced variability among dietary staff. However, improvements were not durable, likely reflecting the limited reach and lack of reinforcement inherent to an intermittently delivered, onboarding-only intervention and a potential ceiling effect within an existing multimodal HH compliance program. These findings emphasize the importance of reinforcement strategies when designing HH interventions for dietary staff to sustain improvements and enhance patient safety.

Background: Legionella is the etiologic agent of Legionnaire’s disease and Pontiac fever with an environmental niche in potable water systems. Globally, Legionella mortality is estimated to have increased fourfold since 1990. Several regulations have emerged to try and counteract this increase, with six countries (Netherlands, Germany, England, France, Australia, and Canada) enacting laws that target the growth of legionella from environmental samples for primary prevention. The effectiveness of these laws in mitigating legionella mortality has not been evaluated. We performed an interrupted time series analysis to evaluate the effect of laws with specific colony forming unit (CFU) thresholds on the legionella mortality rate in the country. Methods: We extracted legionella mortality rate estimates produced by the Global Burden of Disease project for the six countries with legionella laws with defined CFU thresholds for the ten years before the laws were enacted and ten years after the laws were enacted (or up to 2020). We then performed an interrupted time series analysis for these six countries. All analysis was performed in R version 4.5.2. Results: The median legionella mortality rate for the six countries included in analysis in the decade before laws were enacted was 2.86 deaths per 100,000 (IQR1.6-3.75). In the decade following law enactment the mortality rate was 3.35 legionella deaths per 100,000 (IQR 2.01-4.77). In the interrupted time series, there was an increase in legionella mortality of 0.17 deaths per 100,000 (95%CI 0.14 – 0.2) per year in the decade before CFU laws were introduced. The rate of increase did not statistically significantly change after law enactment with an annual increase of 0.102 per 100,000 (95%CI 0.03 – 0.17) persons. A country specific analysis found that the rate of annual increase in legionella mortality rates was statistically significantly lower following enactment of CFU specific laws in Germany, Netherlands, and the United Kingdom (Figure1). Discussion: We found that, collectively, laws including CFU thresholds had no significant effect on the rate of change in legionella mortality. However, at the individual country level, three countries did see a significant decrease in the rate of change in legionella mortality following enactment. One possible explanation for this heterogeneity is that several of these laws include additional mitigation measures and may confound the effect of the CFU based monitoring. Future studies should focus on these additional mitigation measures and compare legionella outcomes in countries with and without CFU thresholds in water safety laws.