Background: Acute bacterial rhinosinusitis (ABRS) is a common, often self-limited condition that frequently leads to inappropriate antimicrobial prescribing in children. Continued reliance on the 2013 American Academy of Pediatrics (AAP) sinusitis guidelines and limited awareness of newer recommendations—particularly those supporting shorter treatment durations—have contributed to antibiotic overuse. As part of an enterprise-wide antimicrobial stewardship initiative, an intervention was implemented to support outpatient pediatric clinicians in identifying children most likely to benefit from antibiotics and in prescribing a 5-day course of guideline-concordant therapy consistent with the 2024-2027 AAP Red Book. We evaluated the impact of this intervention on prescribing practices and clinical outcomes. Methods A retrospective study was conducted among pediatric outpatients diagnosed with uncomplicated ABRS between January 1 and December 1, 2025 at an urban primary care pediatrics clinic within a large health system. The intervention consisted of a brief, targeted educational lecture delivered at a division meeting by pediatric antimicrobial stewardship leadership (pharmacist and physician), emphasizing updated guidance and promoting use of a sinusitis Epic order set. A one-page summary infographic was also distributed for reference. Data were extracted using Epic SlicerDicer and included patient demographics, clinical presentation, antibiotic selection and duration, use of the sinusitis order panel, and clinical outcomes. Outcomes before and after the intervention (May 14, 2025) were compared. Results A total of 99 pediatric patients with uncomplicated ABRS were included, with 55 treated before and 44 after the intervention. Use of the sinusitis order panel increased from 16% to 39% of encounters. The proportion of patients meeting diagnostic criteria for ABRS decreased slightly from 95% to 91%. Prescribing of 5-day antibiotic courses increased from 11% to 34%. There were no significant differences in prescribing provider type, antibiotic selection, or clinical outcomes—including Clostridioides difficile infection, return outpatient visits, or hospital admissions related to ABRS within 30 days—between patients receiving 5 versus <5 days of antibiotics (p<0.05). Conclusions A single, brief educational intervention paired with promotion of an Epic order set and summary infographic increased prescribing of shorter (5-day) antibiotic courses for pediatric ABRS without adversely affecting short-term clinical outcomes. Further studies are needed to assess the durability and long-term impact of this intervention on prescribing behavior.

Behavioural design processes have proliferated in recent years across a diverse set of fields including policy, product development and health. However, this diversity of perspectives also increases ambiguity regarding which (and when) processes should be enacted, which hinders research and practice across fields. This drives two research questions: (1) How are behavioural design processes currently framed, described, and enacted? and (2) How can we consistently understand commonalities and differences across behavioural design processes? In response to these questions, we adopt a critical interpretive synthesis (CIS) approach, reviewing 12 processes from academic and practitioner sources selected through purposive sampling and analysed using a theory-informed coding protocol. Through interpretive synthesis, we re-characterise behavioural design in terms of an ecosystem of distinct but complementary processes rather than its typical presentation in fixed sequences of steps. This increases behavioural design’s ability to respond to different degrees of uncertainty and dynamism in the problem and solution as well as its ability to reflect diverse assumptions about uncertainty, iteration, outcomes and practitioner capability. This research supports an important and developing interdisciplinary area by bringing design process into a design science research context through which many of these topics can be further discussed and developed.

While malaria transmission in coastal East Africa is strongly shaped by climatic variability, few studies examine long-term interactions in rapidly urbanizing settings. This study evaluated the impact of climate and seasonal trends on malaria incidence in Dar es Salaam, Tanzania (2014–2024). Monthly cases and meteorological data were analyzed using seasonal-trend decomposition (STL) and generalized additive models (GAMs) to quantify nonlinear and lagged climatic associations. Over the decade, malaria incidence declined sharply from >130 cases per 10,000 in 2014 to <30 by 2023. However, strong seasonal peaks persisted, with STL revealing consistent annual surges during April–June following the rainy season. GAM analysis identified rainfall as the dominant climatic driver, demonstrating significant 1- and 2-month lagged effects (p < 0.001). Daytime (1-month lag) and night-time (2-month lag) temperatures showed non-linear associations, peaking in incidence at optimal mosquito-development temperatures (~30–31°C). Despite substantial incidence declines, transmission remains highly climate-sensitive. Driven primarily by lagged rainfall and temperature effects rather than current-month conditions, these dynamics underscore the urgent need for climate-informed early warning systems and targeted seasonal interventions in coastal urban environments.

Title: Hospital-onset influenza and RSV: Impact of Infection Prevention Efforts During the COVID-19 Pandemic Authors: Emily Schmitz, MD, MPHa Laura Anderson, RN, MPH, CICb Daniel Shirley, MD, MSa,b,c Affiliations: University of Wisconsin School of Medicine and Public Health, Madison, WI UW Health, Madison, WI Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI Objective: To quantify and characterize hospital-onset influenza and respiratory syncytial virus (RSV) cases, pre- and post- COVID-19 pandemic. Design: Retrospective cohort study from January 1, 2018 - December 31, 2024. Setting: This study was conducted at a large urban Midwestern tertiary-care hospital system. Participants and Interventions: The Infection Prevention team reviewed the electronic medical records (EMR) of patients who were admitted > 48 hours and subsequently tested positive for influenza and/or respiratory syncytial virus (RSV). Incubation periods for each virus were determined based on Centers for Disease Control and Prevention (CDC) guidance and literature review. Hospital-onset was defined as a positive test three or more days after admission for influenza and six or more days after admission for RSV. Patients were excluded if a positive test did not meet these criteria or was completed at least 1-week prior to admission. Clinical data including medical comorbidities, anti-viral administration, vaccination and immunocompromised status were collected from the EMR. Hospital-associated influenza and RSV data were taken from the Wisconsin Communicable Disease Surveillance Data. Results Forty-nine patients met criteria for hospital-onset influenza infection, and 44 (89%) were symptomatic. Twenty-one (43%) patients required the intensive care unit (ICU) and mechanical ventilation during their hospitalization. The majority of patients (92%) received anti-viral therapy (oseltamivir). Nineteen patients (39%) were immunocompromised. A total of 30 (61%) were vaccinated against influenza for the season. Three patients died during their hospitalization, for an in-hospital mortality rate of 0.06%. Nineteen patients met criteria for hospital-onset RSV infection and 18 (95%) were symptomatic. In patients with RSV, 6 (32%) required the ICU and mechanical ventilation during their hospitalization. Only 5 patients (26%) received antiviral therapy for their RSV infection. Compared to influenza, hospital-onset RSV was associated with a higher in-hospital mortality rate (n=3, 16%). There were no hospital-onset influenza or RSV cases from April 2020 through March 2022, which coincides with the COVID-19 pandemic. Cases increased with 12 cases of hospital-onset influenza and 6 cases of hospital-onset RSV in 2024, which were similar to pre-pandemic rates. Discussion Hospital-onset influenza and RSV lead to significant morbidity and mortality. These preventable infections also put healthcare workers and other patients at risk. Data suggest that enhanced infection prevention efforts during the COVID-19 pandemic mitigated the number of hospital-onset cases of influenza and RSV. During periods when influenza and RSV rates are high, enhanced infection prevention efforts are likely warranted to prevent hospital-onset cases.

Background: Current US healthcare-associated infection (HAI) surveillance misses many serious nosocomial infections. Electronic identification of hospital-onset sepsis using CDC Adult Sepsis Event (ASE) criteria could expand the breadth and efficiency of HAI surveillance, but little is known about the preventability of these events. Methods: We identified hospital-onset sepsis events on hospital day ?4 using updated ASE criteria amongst adults admitted to 9 hospitals in Massachusetts, 2021-2023. We randomly selected 224 sepsis events to adjudicate infection probability and source (50% academic, 50% community hospitals) and then analyzed 100 confirmed infections for preventability using a 6-point Likert scale. Two physicians reviewed cases for infection source, following joint review and discussion of the first 25 cases with two senior physicians to standardize approach. All preventability assessments were classified by consensus amongst three physicians. Results: Amongst 224 hospital-onset sepsis events, 100 (45%) had definite or probable infection, 82 (37%) had possible infection, and 42 (19%) had no infection. Most sepsis events were due to respiratory (47%), bloodstream (16%), abdominal (13%) and urinary (9%) infections (Figure 1). Only 11 events were CMS-reportable NHSN HAIs (mostly central-line associated bloodstream infections and catheter-associated urinary tract infections). Crude inpatient mortality for hospital-onset sepsis cases was 35%. Amongst 100 cases assessed for preventability, 30% were judged potentially preventable (Figure 2), most commonly due to lapses in managing established infections (41%) including delays in source control, microbiologic testing, antimicrobial administration, imaging, and subspecialty consultation. Gaps in nosocomial respiratory infection prevention measures were also common (36%) including insufficient oral care, lack of dysphagia management, and failure to mask (Figure 3). Lapses in traditional device-related HAI prevention bundles were uncommon (7%). Some hospital-onset sepsis events may have been preventable with better general medical care (17%), including earlier recognition and management of non-infectious contributors to physiologic deterioration (e.g., earlier diuresis to optimize respiratory reserve among patients at risk for aspiration, proactive bowel management to prevent stercoral colitis and downstream infectious complications). Conclusions: Hospital-onset sepsis events identify serious, often fatal infections, many of which are potentially preventable. Opportunities extend beyond current HAI prevention bundles and include the need for more timely recognition and management of established infections to prevent progression to sepsis, introducing measures to prevent nosocomial respiratory infections, and improving general inpatient medical care. Incorporating hospital-onset sepsis surveillance into infection prevention and quality improvement programs could help identify actionable steps to improve the safety and quality of inpatient care.

Background: Outpatient parenteral antimicrobial therapy (OPAT) is a common approach to treating complex infections, offering benefits of higher patient satisfaction, reduced risk of hospital-acquired infections, and lower healthcare costs. However, limited information exists regarding how OPAT is delivered across U.S. healthcare systems. We sought to understand OPAT practices and identify facilitators and barriers to OPAT delivery at Veterans Affairs (VA) medical centers (VAMCs), which constitute the largest integrated healthcare system in the U.S. Methods: We conducted a national survey of VAMCs between January-April 2025. OPAT providers were invited via email to complete an online Qualtrics survey. Topics included care delivery, patient monitoring, and perceived challenges to safe, effective OPAT care. Data were summarized using descriptive statistics. Results: Of 139 surveys, 106 (76.3%) were completed and analyzed. Most VAMCs offered OPAT (78/106; 73.6%). Among those, 60/78 (76.9%) designated OPAT providers to monitor and manage care, often Infectious Disease (ID) physicians (54/60; 90.0%) and ID pharmacists (44/60; 73.3%). Dedicated time for OPAT care activities varied by site and role. Guidelines for OPAT care were reported at 45/78 (57.7%) VAMCs, typically outlining eligibility criteria as well as protocols for patient monitoring and follow-up. Generally, VAMCs required ID consultation prior to discharge and discharged 1-10 patients on OPAT per month, most of whom were followed by ID providers. OPAT-related outcomes were measured by about half of VAMCs (40/78; 52.6%); adverse events were most frequently measured. OPAT delivery extended beyond VAMCs through referrals to outside healthcare systems and collaboration with contract infusion pharmacies and home health agencies (Table 1). Respondents noted challenges to providing safe OPAT care, including dedicated time, communication with organizations outside the VA, and timeliness of labs (Figure 1). Conclusions: While individual VAMCs varied in delivery practices, key elements across programs included designated providers and defined OPAT care components. Challenges were driven by fragmented care, which hindered communication and coordination. Expanding VAMC capacity to provide OPAT and monitor patients may streamline communication, delivery, and continuity. A process map for referrals outside the VA may help designate roles and responsibilities for monitoring and providing OPAT care.

Late HIV diagnosis increases morbidity and mortality. In this retrospective cohort study on the national HIV register, we analysed risk factors for late HIV diagnosis among newly registered people living with HIV (PLWH) between 2008 and 2023, using the updated definition. Of 2683 PLWH registered, 1813 (67.6%) were newly diagnosed with CD4+ T-cell count available ≤90 days for 1572 (86.7%). Eighty-seven of the 609 (14.3%) individuals with CD4+ T-cell count <350/μL had recent infections and were reclassified as non-late. Of the newly diagnosed, 50.3% were diagnosed late. Multivariable analysis identified higher age as an independent risk factor for late diagnosis (adjusted OR 1.42 per ten years, 95% CI 1.30–1.56). Of the Finnish-born, females had lower odds than males (aOR 0.59, 95% CI 0.39–0.88). Asian-born (aOR 6.83, 95% CI 3.49–13.35) and African-born females (aOR 3.26, 95% CI 1.58–6.73) had significantly higher odds than Finnish-born females. In urban municipalities, men who have sex with men had lower odds than individuals with heterosexual transmission (aOR 0.55, 95% CI 0.40–0.76). Higher age was the most important factor for increasing the proportion of late diagnoses. We recommend enhanced testing and risk awareness for older adults and migrants from high-prevalence countries.

Background: During a measles outbreak in the United States in 2025, health care settings were on high alert for patients who may have been exposed to or infected with this disease. When an infection is found, contact tracing investigations are extensive and require significant labor. Identify, Isolate, Inform (III) has become a standard tool for special pathogen preparedness. Our facility implemented an electronic medical record (EMR) alert for patients reporting fever and rash. The objective of this work is to compare and contrast our experience in drill vs clinical practice. Methods: Setting. Denver Health is an acute-care safety net hospital with both adult and pediatric emergency departments, sharing a common security checkpoint for entrance, and a check in and arrival space before patients are triaged into individual waiting rooms. Drill. In March 2025, Denver Health conducted a drill to test the III process in the pediatric emergency department and urgent care center (PEDUC) where care was provided for a mock patient with fever, rash, and cough. Time to masking and time to isolation were collected by a drill observer. Clinical practice. In April 2025, an infant with recent international travel presented to the PEDUC with cough, fever, and rash and was subsequently diagnosed with measles by PCR. Time to isolation was collected via time stamps in the EMR. Results: During the drill, fever and rash were documented, and the alert fired appropriately. The mock patient was masked within six minutes of entry and roomed in a negative pressure room within nine minutes of entry. During clinical practice, rash was documented, but the patient was afebrile at triage, and the EMR alert did not fire. The patient spent 62 minutes in the waiting room before being roomed. Contact tracing involved individuals in both the adult and pediatric emergency departments due to the shared airspaces. In total, 149 patients were identified as contacts and were notified of the exposure by public health. No transmission was identified. Conclusions: Despite a recent successful drill in the PEDUC, when a patient presented with measles, there were challenges with identification and isolation, as well as structural limitations within the facility and gaps with technology aiding the early identification of patients at risk. Having a real-life situation resulted in an extremely large contact investigation and juxtaposed the recent successful drill, highlighting the need to continue performing “no notice drills” and work on improving each facet of preparedness.

Background: Respiratory Syncytial Virus (RSV) is a leading cause of infant hospitalizations in the United States and is particularly devastating to infants 6 months and younger. Maternal RSV vaccination given more than two weeks before delivery and early infant nirsevimab administration can provide protection against severe illness in this vulnerable population. Objective: To evaluate uptake of, and barriers to, RSV immunization among infants admitted to the hospital with RSV infection in a large healthcare system. Additionally, clinical outcomes between infants who did and did not receive any RSV protection were compared. Methods: This was a retrospective cohort of infants ? 6 months old hospitalized in a large multi-state healthcare system from November 2024 to January 2025 with a positive RSV test within 7 days prior to or during admission. Patients were identified using an electronic health record report and chart review was performed to obtain data on RSV immunization and clinical outcomes. Infants born outside of our healthcare system where information on RSV immunization was lacking were excluded. Infants were classified as protected if either 1) maternal RSV vaccination was given more than two weeks before delivery or 2) the infant received nirsevimab prior to the onset of RSV infection. All others were classified as unprotected. Clinical outcomes including length of stay, ICU admission, and mechanical ventilation were compared between groups. Identification of barriers to RSV immunization were attempted. Result: Of 152 infants admitted with RSV, 103 were born in our hospitals and included. 17 (16.5%) patients were considered protected (8 with maternal vaccination; 9 infant nirsevimab administrations). Patients in both groups were predominantly male and either Non-Hispanic White or Hispanic. Compared to unprotected patients, protected patients had significantly fewer ICU admissions (0% vs 28%, p = 0.03) and shorter median length of stay (1 vs 2 days, p=0.004). There was no difference between groups in rates of mechanical ventilation or death. Among unprotected patients, chart review most often showed no documentation of any RSV immunization discussions (75.6%), family declined treatment (12.8%), and infants becoming ill before nirsevimab could be administered despite willingness to eventually receive it (11.6%). Post-RSV infection, an additional 12% of unprotected patients received nirsevimab. Conclusion: Unprotected infants were more likely to experience negative clinical outcomes, specifically more ICU admissions and longer hospitalizations. Opportunities exist to improve RSV provider and family education and implement interventions to facilitate discussion and administration of RSV prophylaxis.

Background: Multiplex syndromic polymerase chain reaction (PCR) panels can rapidly identify pathogens in patients with diagnosis of pneumonia, but they may also detect colonizing bacteria, which can lead to diagnostic uncertainty. Their utility in sputum samples remains unclear, as most evidence comes from higher-quality bronchoscopy specimens. To ensure these tests are used in scenarios with the greatest clinical impact, such as when results can be returned quickly and guide treatment, we developed a clinical decision support tool. The tool restricts ordering of multiplex pneumonia PCR panel on sputum samples to patients with severe illness or immunocompromise. Methods: The study was conducted at a New York City hospital system. Beginning in December 2024, the pneumonia PCR panel decision support tool was implemented and restricted ordering on sputum samples to patients who were admitted to the intensive care unit (ICU), prescribed vasopressors, required at least high flow nasal cannula for supplemental oxygen, had solid organ or hematopoietic transplant, received Gram negative coverage with meropenem or broader for 48 hours without improvement, and/or infectious diseases or pulmonary attending consult recommendation. We analyzed the total number of sputum pneumonia PCR panels and associated positivity rates prior to and after implementation of the decision support tool during quarters 1 through 3 of 2023, 2024 and 2025. Results: After intervention implementation, the overall number of sputum pneumonia PCR panels ordered decreased by 34%. At $200 per PCR panel, this represents a cost savings of at least $208,000. The greatest change was on non-ICU inpatients, where the total decreased from 1267 in 2024 to 504 in 2025 (60%, Figure 1). The emergency department had a decrease from 266 in 2024 to 125 in 2025 (53%). There was minimal change in PCR panel usage in the ICU and outpatient, which are areas not targeted by the intervention. The positivity rate was consistent over the three years (70-75%). Most sputum PCRs detected multiple bacterial organisms (57-70%, Figure 2a) and 5-11% of samples detected bacteria at a quantity of only 10^4, with or without viral co-infection (Figure 2b). After reviewing post-implementation quarter 1 2025 data, broad Gram-negative coverage was removed as a testing criterion since it was selected frequently (32%) but not accurately (10% accuracy). Conclusion: Implementation of a clinical decision support tool in Epic led to more appropriate diagnostic stewardship of the multiplex pneumonia PCR, improving care and reducing costs. Future interventions will target improving stewardship in the ICU.

Background: We describe an investigation of a cluster of eight Corynebacterium amycolatum sternal surgical site infections (SSIs) that occurred among cardiac surgery patients from February to October 2025. Although C. amycolatum is a member of the skin microbiota, clinically significant infections caused by this organism may occur in cardiac surgery patients. Methods: The investigation included retrospective reviews of SSIs, clinical cultures and medical records, surgical observations, and operating room (OR) assessment. Line lists of surgical case criteria and infection prevention practices were created to assess common factors among cases (e.g., staffing, instrumentation, equipment, skin preparation and antisepsis, nasal decolonization, antibiotic protocols, and closure). Whole genome sequencing of isolates was performed and analyzed using SNIPPY for single-nucleotide polymorphism (SNP)-based phylogenetic analysis. Results: Phylogenetic analysis indicated isolates from five of eight case patients who had cardiac surgeries occurring over a six-week period from February to April 2025 were genetically related (?7 SNPs across the genome), suggesting a common source of infection. These five isolates were ceftriaxone, meropenem, and penicillin resistant. The other three case patient isolates were unrelated (<3181 to <15,000 SNPs); two were ceftriaxone, meropenem and penicillin resistant (one also doxycycline intermediate resistant), and the third penicillin resistant. Use of sternal tape for closure was identified as a recent practice change. Four of five genetically related cases involved the same surgeons and suture tape for sternal closure (wire for all other cases). Sternal tape was discontinued with three cases occurring afterwards. Seven patients completed chlorhexidine gluconate bathing and nasal decolonization. Hair was removed in the OR with reusable surgical clippers. All received the same skin antiseptic, and antibiotic prophylaxis was appropriate. No trends were identified in instrument or equipment use. Broad infection control measures were implemented, including surgical clipper replacement, OR cleaning and ultraviolet light disinfection, headlamp cleaning, and environmental repairs. Leadership was engaged through frequent meetings and audits. Infection control practices such as minimizing OR traffic, double gloving, glove changes, and strict adherence to hand hygiene and attire were reinforced. Two of eight cases occurred after these recommendations were completed but were not genetically related to the primary cluster. Conclusion: We describe a cluster of invasive C. amycolatum sternotomy SSIs. Only two genetically unrelated cases of C. amycolatum occurred following infection control investigation and interventions, underscoring the effectiveness of a comprehensive, multidisciplinary approach. This organism has rarely been reported as a cause of SSIs and may be an emerging pathogen.

Introduction: Surgical site infections (SSI) account for 20% of all healthcare-associated infections (HAIs). SSI are associated with increased patient mortality, morbidity, length of hospitalization and risk of readmission with an associated total healthcare cost of $3.3 billion annually. Of the reported SSIs, colorectal (COLO) surgeries have been among the highest risk procedures. A crucial element to prevent HAI is the accurate identification of true events. This allows for comparison of facility-specific performance metrics with peer groups and the development and implementation of targeted interventions to reduce SSI burden. In this abstract, we assessed the impact of multidisciplinary intervention to accurately identify, and document visualized infections on SSI rates and Standardized Infection Ratios (SIR) at a tertiary care teaching facility. Methods: A quasi-experimental study was conducted from 02/01/2024 to 06/30/2025 to improve the accuracy of operative note documentation of visualized infections. Indicators to evaluate possible SSI events included readmission(s), chief complaint, surgical logs, diagnostic codes, antibiotic use, lab/culture data and keywords that may indicate a surgical site infection. Subsequently identified procedures were evaluated by the Surveillance Infection Preventionist team, the Medical Director of Infection Prevention, and the Surgical Quality Officer. If indicated, the operating surgeon was consulted to determine whether visualized infection criteria were met and/or correctly documented. Turnaround time for case reviews was determined. We compared the observed SSI rates and Standardized Infection Ratios (SIR) with the uncorrected rates and SIR accounting for the clarified events. Results: Of 1,142 procedures, 55 were initially identified as COLO SSI. After multidisciplinary review, 12 (22%) of the 55 were found to be present at the time of surgery (PATOS). An additional two events (4%) were determined to not meet SSI criteria. The table summarizes the results of the review process showing a statistically significant correction in SSI event rates from 4.82/100 surgeries to 3.59/100 surgeries (p<0.0001). The turnaround time from identification of a potential SSI event to final determination was four days (range: 1-6 days). Conclusion: Surgical site infection events are critical quality outcome measures for both regulatory and reputational agencies. However, the misclassification of SSIs, such as observed in our study, can create a misleading picture of institutional performance, divert attention from preventable cases, and undermine confidence in surveillance systems. Our multidisciplinary approach ensures a more accurate identification of SSI events. This method can serve as a model for enhancing surveillance accuracy and reliability across healthcare settings.

Background: Clostridioides difficile Infection (CDI) is one of the leading causes of hospital-acquired infections. The Veterans Health Administration launched a national CDI prevention initiative in 2012 that bundled core practices such as environmental cleaning, strict hand hygiene, and contact precautions. In contrast to prior studies which have noted a decline in CDI rates during the COVID-19 pandemic, rates of hospital-onset (HO)-CDI increased at our Veterans Administration Hospital, and we sought to address this issue with a multi-pronged approach. Methods: We assessed multi-modal approaches implemented to reduce HO-CDI rates at Veterans Affairs North Texas Health Care System (VANTHCS), a large, academic VA medical center from 2021 to 2025. This approach included laboratory changes to CDI testing, updates to infection prevention practices, and antimicrobial stewardship program (ASP) rounds for prospective audit and feedback for antibiotics (including those considered high-risk for CDI by the National Healthcare Safety Network). Our primary objective was to assess the impact of these interventions on the incidence of HO-CDI, comparing HO-CDI rates before (Q2 2020–Q4 2022) and after (Q2 2023–Q3 2025) their implementation. HO-CDI was defined as a LabID event collected from an inpatient location < 3 days after admission (i.e., on or after hospital day 4), and rates were reported as number of HO-CDI/10,000 bed days of care (BDOC). Cases were extracted from the Computerized Patient Record System. Results: In October 2021, VANTHCS switched from a standalone nucleic acid amplification test (NAAT) to a 2-step algorithm wherein an initial NAAT was reflexed to a toxin immunoassay if positive. The Infection Prevention and Control Program developed standard operating protocols for room cleaning and disinfection, and hand hygiene was reinforced. In February 2023, the facility ASP implemented thrice-weekly rounds. Institutional antimicrobial guidelines were developed for common infections, and educational presentations were delivered to providers, using illustrative cases to highlight key stewardship principles. ASP team members audited 2,282 patient charts from April 1, 2023, through September 30, 2025. Interventions were made for 1,215 (53%) patients, and prescribers accepted 972 (80%) recommendations. Common interventions consisted of either antibiotic discontinuation or de-escalation in 74% of patients. Mean quarterly high-risk CDI antibiotic use declined from 95 to 71 per 1,000 BDOC (25%, p<0.01), and HO-CDI rates declined 59% from 3.81 (pre) to 1.55 (post) infections per 10,000 BDOC. Conclusion: A multipronged approach of reinforcing IPC practices, 2-step testing, and targeted feedback for antibiotics use led to significant decreases in HO-CDI rates.

Background: Patients undergoing hepato-pancreato-biliary (HPB) surgery routinely need central venous access for chemotherapy or parenteral nutrition. Common postoperative complications of HPB surgeries include cholangitis and transient bacteremia from biliary tract manipulation. Previous studies have suggested that the National Healthcare Safety Network (NHSN) criteria that designate bacteremia secondary to infections such as cholangitis, may be too strict to account for these situations, resulting in central line associated bloodstream infection (CLABSI) misattribution. Methods: This retrospective study evaluated bacteremia events within 30 days of an HPB surgical procedure among patients ≥ 18 years old at a large academic medical center in the United States. The study period included January 1, 2024 through October 31, 2025. HPB procedures were identified using operative codes mapped to HPB surgeries by NHSN with bacteremia cases identified electronically. CLABSI cases, as established by NHSN criteria, underwent manual chart review to understand the clinical context. Results: There were 1,143 HPB surgeries within the study period. Bacteremia was detected in 35 of them (3.1%). Five of these were ruled in as CLABSI. CLABSIs occurred at an average of 9.6 days postoperatively and 7.6 days after central line placement or access. CLABSIs were due to Enterococcus faecalis, Candida krusei, Prevotella species, Klebsiella oxytoca, and Staphylococcus aureus. Three of the CLABSIs had clinical evidence of cholangitis, but imaging findings were insufficient to meet NHSN criteria for an intraabdominal infection. These cases included transient bacteremia within 24 hours of biliary manipulation (drain placement for a portobiliary fistula, n=1, and drain capping, n=2). The other two CLABSI cases did not undergo biliary manipulation during their hospitalization and had no clear evidence of secondary infection. Conclusion: A substantial number of CLABSIs in HPB surgical patients may represent misattribution. Consideration to the unique infection risks of HPB surgical patients such as transient bacteremia related to drain placement and exchange could minimize CLABSI misattribution in this patient population. Ellsworth, M. G., Ausborn, V., Patel, B., Chang, P., & Ostrosky-Zeichner, L. (2023). 2419. Increasing Misattribution of Bacteremia as CLABSIs by NHSN Definitions: A Tertiary Care Center Perspective. Open Forum Infectious Diseases, 10(Suppl 2), ofad500.2039. https://doi.org/10.1093/ofid/ofad500.2039

Background: Inappropriate urine culture ordering in hospitalized patients with indwelling urinary catheters contributes to unnecessary antibiotic exposure and increased risk of catheter-associated urinary tract infections (CAUTI). Urine Culture Stewardship Interventions have emerged as strategies to reduce unnecessary urine culture testing and downstream antibiotic use; however, the magnitude of their impact across clinical settings remains incompletely characterized. Methods: We conducted a scoping review following PRISMA-ScR guidelines to identify studies evaluating urine culture stewardship interventions in hospitalized adults (≥18 years) with indwelling urinary catheters. A systematic literature search was performed in PubMed, Cochrane Library, Web of Science, and Scopus from inception through June 2025, using predefined terms related to indwelling urinary catheters, urinary tract infections and CAUTI, urine culture and diagnostic stewardship, antibiotic use, and catheter management strategies. Interventions included reflex urine culture protocols, catheter replacement prior to specimen collection, educational initiatives, and multicomponent stewardship bundles. Outcomes of interest were urine culture utilization, CAUTI rates, and antibiotic utilization. Data were extracted independently by two reviewers using Covidence. Results were synthesized descriptively, and ranges of relative change were calculated by the review authors when pre- and post-intervention rates were explicitly reported. Results: Conclusion: Urine culture stewardship interventions in hospitalized adults with urinary catheters are consistently associated with meaningful reductions in urine culture utilization and CAUTI rates, with variable but generally favorable effects on antibiotic use. Education-based and reflex urine culture strategies, particularly when embedded within multicomponent stewardship bundles, appear most frequently studied and effective. These findings highlight the potential of diagnostic stewardship as a key component of infection prevention and antimicrobial stewardship efforts, while underscoring the need for standardized outcome reporting and to better quantify downstream clinical impact.

Background: Carbapenem-resistant organisms (CRO) and Candida auris are multidrug-resistant organisms (MDRO) that can spread between patients and environments, posing a threat to health care systems, including acute care hospitals and nursing homes. However, their impact on non-nursing home congregate residential facilities, such as homeless shelters and assisted living facilities, is poorly understood. These facilities traditionally lack infection prevention and control (IPC) capacity as compared with health care facilities, have multi-occupancy rooms, and may have high censuses, all of which facilitate disease spread. Methods: To inform opportunities for public health intervention, clinical CRO and C. auris cases were enumerated from results reported to the New York City Health Department during 2019–2024. Patients’ geocoded addresses were matched to a list of non-nursing home congregate residential facilities. Cases were counted once during the study period, in alignment with the 2023 Council of State and Territorial Epidemiologists Carbapenemase-Producing Organisms and C. auris case definitions. CRO cases were counted separately for each organism/carbapenemase combination among patients where multiple combinations were reported. Cases’ demographic, isolate, and residential facility characteristics were summarized using univariate statistics. Results: During 2019–2024, 97% (11507/11858) of CRO and 100% of 1848 C. auris cases were reported with complete addresses. Of those, 471 (4%) CRO and 89 (5%) C. auris cases’ addresses matched a non-nursing home congregate residential facility at the time of diagnosis. Most CRO (63%) and C. auris (70%) cases were male. The median age at diagnosis for CRO cases was 64 years (interquartile range: 52–100 years) and for C. auris cases was 60 years (interquartile range: 51–69 years). Most laboratory tests originated from inpatient facilities for both CRO (65%) and C. auris (71%) cases. Among CRO and C. auris cases whose addresses matched to a congregate setting, the most common non-nursing home congregate facility types were group homes for people with intellectual and developmental disabilities (33% and 38%, respectively), shelters for people experiencing homelessness (25% and 26%), assisted living facilities (22% and 15%), and housing for people with mental health conditions (14% and 18%). Conclusion: More research is needed regarding CRO and C. auris in congregate settings. People residing in these environments may benefit from tailored approaches to MDRO case management. Enhanced surveillance by health departments in the form of routinized geocoding and address matching, which is low-cost and uses existing data sources, can identify facilities that could benefit from IPC support, education, and resource distribution.

Background: Over the past decade there has been an increased focus on infection prevention in post-acute care settings, including long-term care (LTC), skilled nursing facilities (SNF), rehabilitation facilities and home health. Many of these settings provide care for older people with complex care needs. Research has shown high rates of inappropriate antibiotic prescribing, with sub-optimal drug choice, dosing and duration – all targets for antimicrobial stewardship programs (ASP). Although national guidance is available, implementation remains challenging. In this study, we explored the structure and leadership of ASP in a variety of post-acute care settings from an infection prevention perspective. Methods: Infection Preventionists (IPs) were invited to participate in the 5-yearly Association for Professionals in Infection Prevention (APIC) Megasurvey. The electronic survey was advertised using snowball recruitment by APIC between June 6 and July 31, 2025. Data were collected on ASP characteristics, including structure and leadership of programs, and resources available to support appropriate prescribing. Descriptive statistics were used to summarize the data. Results: A total of 489 respondents reported working in post-acute settings. Of these 239 (49%) worked in long term care, 200 (41%) in skilled nursing facilities, 26 (5%) in inpatient rehabilitation and 24 (5%) in home health. Facility-based post-acute care IPs overwhelmingly reported the existence of ASPs (LTC-82%; SNF/Rehabilitation – 93%) with a committee having oversight (LTC-86%; SNF/Rehabilitation – 80%). This governance function was often incorporated into infection prevention committees (LTC - 52%; SNF/Rehabilitation – 43%). In LTC, ASPs were led by a range of healthcare professionals including IPs (27%), infectious diseases (ID) physicians (10%), ID pharmacists (10%), pharmacists (non-ID) (23%), and other medical professionals such as internists (22%). In SNFs/ Rehabilitation facilities, a similar pattern was observed. IPs reported they had up-to-date recommendations available for infection management (LTC - 88%, SNF/Rehabilitation -83%), and around half also noted existence of regular rounds to allow inquiry about appropriate antibiotic prescribing (LTC - 52%, SNF/Rehabilitation - 53%) Only 29% of IP respondents from home health reported having an ASP. Although numbers are small, it appears that 70% of these programs had the governance of an ASP Committee but there was little IP involvement in leadership or antibiotic prescribing review activities. Conclusion: This study provides unique insights into ASP in post-acute care. Programs are now well-established in many facility types. More work is needed to understand and help IPs develop ASP expertise relevant for post-acute settings, particularly in home health.

This study investigated the size and distribution of university-based journals published in federal universities of North-Western Nigeria. Using an exploratory descriptive survey design, data were gathered from institutional lists, university websites, and physical serial holdings in libraries of the universities. A total of 243 journals were identified across ten universities, with Ahmadu Bello University, Zaria, Bayero University, Kano, and Usmanu Danfodiyo University, Sokoto collectively accounting for more than half of the total. Social sciences, arts, and humanities dominated the disciplinary distribution, while STEM, health sciences, and agriculture accounted for smaller shares. An important finding was that most university libraries did not maintain complete holdings of the journals published in the parent institution, revealing weaknesses in distribution strategy, bibliographic control and preservation. The study concludes that although journal proliferation is evident, visibility and long-term archiving remain problematic. It recommends the establishment of institutional and national journal registries, stronger archiving practices, and total migration to digital platforms to enhance access and global recognition of the journals.

Background: Social deprivation may affect both infection severity and the quality of antibiotic prescribing, but its influence on downstream outcomes and the role of stewardship processes in this pathway remain uncertain. Methods: We conducted a retrospective cohort study of 1,365,957 emergency department (ED) encounters among older adults across multiple U.S. hospitals, 2013–2022. We assessed the impact of community social deprivation on clinical outcomes and identified mediation through antibiotic prescribing (guideline-concordant empiric use). Social deprivation was quantified using a z-scored Social Deprivation Index (SDI). Outcomes were log-transformed length of stay (LOS), 30-day ED revisit, 30-day mortality, 30-day C. difficile infection, and DOOR (Desirability of Outcome Ranking; 1=alive with LOS at or below the median and no 30-day events, 2=alive with LOS above the median and no events, 3=30-day ED revisit, 4<=i>C. difficile infection, 5=death). We fitted multivariable ordinary least squares models with state- and month-fixed effects and clustered standard errors, controlling for demographics, comorbidities, clinical severity, travel time, hospital characteristics, and rurality. We applied regression-based mediation analysis to partition the SDI–outcome relationship into direct effects and indirect effects mediated by prescribing concordance. Secondary models substituted antibiotic overuse or underuse for concordance. Results: Concordant prescribing occurred in 83% of encounters; overuse and underuse occurred in 9.5% and 7.4%, respectively. Higher SDI was associated with slightly worse outcomes: each 1-SD increase corresponded to modestly longer LOS, higher risk of 30-day ED revisit and mortality, and worse DOOR scores, with minimal association with C. difficile infection (Figure 1). Concordance was strongly associated with better outcomes, including shorter LOS, fewer ED revisits, lower mortality, and lower DOOR scores. Mediation analyses (Figure 2) indicated that concordance explained about 11% of the SDI–LOS association and <5% of the associations with ED revisit, mortality, and DOOR. In secondary models (Figure 3), overuse was consistently associated with worse outcomes—longer LOS, higher mortality, and higher DOOR scores—independent of SDI. Underuse showed inverse associations with LOS and DOOR but only tiny, clinically negligible increases in ED revisit and mortality, patterns likely reflecting residual confounding and selection of lower-acuity patients. Conclusion: We found that social deprivation was associated with worse health outcomes, with antibiotic concordance serving as a partial pathway linking deprivation to harm. Stewardship efforts that improve concordance and curb overuse—particularly in socially deprived communities—may help reduce outcome disparities without encouraging under-treatment.

Background: Multiplex respiratory panels are commonly utilized in the clinical care of respiratory infections. This usage occurs despite their high cost and absence of impact on clinical decision making. Guidance from national societies such as the Society of Hospital Medicine and American Association of Family Practice suggest limiting use to immunocompromised hosts or targeted testing based on seasonal prevalence, however clinical practice often does not mirror these recommendations. Methods: We conducted a retrospective review of the ePlex repiratory panel, an automated polymerase chain reaction for detection and identification of multiple respiratory viral and bacterial nucleic acids, at University of Kentucky Healthcare during July 2024-June 2025. Test volumes were stratified by location and month. We assessed the frequency of insurance denials, and the estimated cost of unreimbursed testing. These results were then utilized to create a multi-pronged stewardship intervention. Results: A total of 15,320 tests were ordered, with 32.2% reporting at least one positive analyte, most commonly rhinovirus/enterovirus (25.5%) (Figure 1). Tests were most frequently ordered inpatient (7315 tests, 47.7%). Of the 3787 (24.7%) outpatient tests, urgent and primary care settings accounting for the largest propotion (46.5%). Insurance denials led to an unreimbursed cost of 1.78 million USD. Testing peaked in the winter months (1873 tests in December 2024), with a nadir of 935 tests in August 2024 (Figure 2). The intervention comprised three domains. First, the intervention was discussed and approval sought from key stakeholders including Lab formulary committee, inpatient and outpatient medical directors, Infectious Diseases, Laboratory services, and Pharmacy. Second, a comprehensive modification of the EMR including creation of nested order panels that led ordering users through clinical scenarios to determine if testing was indicated, selection of an appropriate use criteria if the test was ordered, and redirecting keywords to the order panel instead of the individual test order. Last, a patient/caregiver handout was created on supportive care for viral infections, and the lack of impact of multiplex testing in non-immunocompromised hosts. After the interventions went live in late-November 2025, test volume saw a significant decline with a 29% decline in November 2025, and a 73% decline in December 2025 (Figure 2). Conclusion: Our preliminary results show remarkable impact of a comprehensive diagnostic stewardship effort targeting appropriate test ordering of a multiplex viral respiratory panel. We plan to monitor long-term test usage, as well as impact on unreimbursed costs.