Background: Urinary tract infections (UTI) are common in the outpatient setting and a key focus of antimicrobial stewardship efforts. Inappropriate antibiotic prescribing persists, including low utilization of first-line agents. Limited research exists evaluating the drivers of variations in antibiotic prescribing for UTI. This analysis assessed associations between patient, clinician, and neighborhood factors and receipt of a first-line antibiotic for UTI. Methods: A cross-sectional analysis of adult (18 and over) urgent care visits from January 2023 to April 2025 in an integrated academic healthcare system was conducted, assessing antibiotic prescriptions for uncomplicated UTI visits. First-line antibiotics were defined as nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin according to IDSA clinical guidelines. Only visits associated with an antibiotic prescription were included in the analysis. Patient health status was assessed using the Charlson Comorbidity Index (CCI). Neighborhood factors were assessed using the Area Deprivation Index (ADI). Clustered logistic regression models were fit to assess factors associated with the likelihood of receiving first-line antibiotics. Results: A total of 13,092 UTI visits were included, of which 58% received first-line antibiotics. Patients were primarily White (73.7%), female (89.4%), and used commercial insurance (56.9%). The average age was 54.1 years, and the average CCI was 1.9. Age was associated with a lower likelihood of receiving first-line therapy; each additional year of age (<18) was associated with a 1% decrease in odds (Adjusted Odds Ratio (aOR) = 0.99, 95% CI = 0.98, 0.99). Similarly, each one-point increase in CCI decreased the likelihood of receiving first-line antibiotics by 4% (aOR = 0.96, 95% CI = 0.94, 0.97). Compared with men, women were less likely to receive first-line antibiotics (aOR=0.55, 95% CI=0.48, 0.62). Treatment by a physician assistant (PA) (aOR=0.91, 95%CI=0.83, 0.98) or a registered nurse (APRN) (aOR=0.66, 95%CI=0.60, 0.73) was associated with a reduced likelihood of first-line medication. Finally, being on Medicaid (aOR=0.82, 95% CI=0.71, 0.94) or Medicare (aOR=0.82, 95% CI=0.73, 0.91) was associated with a decreased likelihood of receiving first-line antibiotics. No statistically significant association was found between living in a more disadvantaged neighborhood, as measured by the ADI, and receiving first-line antibiotics. Discussion: Being older, female, in poorer health, treated by a PA or APRN, or having Medicare/Medicaid were associated with a lower likelihood of receiving first-line antibiotics for UTI. These findings provide critical information to understand variations in antibiotic prescribing for UTI. Further work is needed to identify the drivers of these differences to improve equity in stewardship.

Background and Objective: Antipseudomonal antibiotics are frequently initiated empirically in hospitalized patients with suspected pneumonia. However, de-escalation often remains suboptimal. Behavioral “nudge” interventions in microbiology reporting have shown potential to enhance antimicrobial stewardship. In June 2022, our institution implemented a revised microbiology comment in sputum culture result reporting emphasizing “commensal respiratory flora only: no MRSA or P. aeruginosa”. This study aimed to evaluate whether this reporting nudge increased de-escalation of antipseudomonal therapy within 24 hours of final respiratory culture results. Methods: We conducted a retrospective cohort study of adults (<18 years) admitted between December 1, 2021 - May 31, 2022 (pre-intervention) and July 1–December 31, 2022 (post-intervention) who had respiratory cultures obtained and were started on at least one antipseudomonal antibiotic within 48 hours of the culture being sent. Patients were excluded if cultures grew P. aeruginosa, if another infection required antipseudomonal coverage, if therapy was required due to allergies, or if they had neutropenic fever. The primary outcome was de-escalation, defined as discontinuation or narrowing of antipseudomonal therapy, within 24 hours of the finalized respiratory culture report. Secondary outcomes included duration of therapy, hospital length of stay, Clostridioides difficile infection within 30 days, and in-hospital mortality. Outcomes were compared in pre- and post-intervention cohorts. Results: Of 230 screened patients, 175 met the inclusion criteria (107 pre-intervention, 68 post-intervention). Approximately one-third of subjects had community-acquired pneumonia(34 in pre-intervention and 28 in post-intervention). Baseline characteristics suggested the pre-intervention cohort had higher severity of illness, with more ICU admissions (N =68 in pre-intervention and N=28 in post intervention) and more hospital-acquired (N= 21in pre and N=8 in post) or ventilator-associated pneumonia (N=7 in pre, N=2 in post). De-escalation within 24 hours occurred in (76) 71% of pre-intervention patients and (50) 73.5% post-intervention (p=0.72). Median duration of antibiotics after final culture result was 1 day (IQR, -1,3) in the pre-intervention group and 0 days (IQR, -2,3) in the post-intervention group (P=0.36). Median hospital length of stay was significantly longer in the pre-intervention group (IQR 13(6,20) vs 9 (5,16); p=0.03). Rates of C. difficile infection (<5%) and in-hospital mortality did not differ significantly between groups. Conclusion: Implementation of a microbiology nudge comment in respiratory culture result reporting did not significantly increase antipseudomonal antibiotic de-escalation. High rates of de-escalation were observed even prior to the intervention. Explanations for the finding may be that respiratory cultures are being sent unnecessarily and, therefore, they are not being used as data to act upon and/or anti-pseudomonal antibiotics are being started empirically unnecessarily, particularly in patients with CAP. The cohorts did differ in severity of illness, which may have impacted the results. These findings highlight the need for additional education regarding guideline-directed respiratory culture utilization and empiric antibiotic choices.

Background: Outbreaks of norovirus and other enteric diseases are common in long-term care facilities (LTCFs) such as nursing homes and assisted living facilities. During the COVID-19 pandemic, LTCFs enacted strict infection control measures which, combined with societal non-pharmaceutical interventions, may have limited the introduction of other infectious diseases, including norovirus, into these settings and reduced disease transmission temporarily. However, a newly predominant strain of norovirus was associated with abnormally high outbreak activity in the 2024-25 winter season. We describe changes to trends in norovirus outbreaks in LTCFs reported to the National Outbreak Reporting System (NORS) and CaliciNet, a strain surveillance platform, during the last decade. Methods: State and territorial health departments voluntarily report foodborne, waterborne, and other enteric outbreaks to the Centers for Disease Control (CDC) and Prevention through NORS. Public health laboratories report laboratory-confirmed norovirus outbreaks and genotypes to CDC through CaliciNet. Merged data from both systems were analyzed across four time periods: pre-pandemic, August 2015 – March 2020; pandemic, April 2020 – July 2021; post-pandemic, August 2021 – July 2024; and the 2024-25 season, August 2024 – July 2025. Both laboratory-confirmed (positive specimens from ≥2 case-patients or as defined by the reporting site) and suspected (<2 positive specimens) etiology outbreaks were included. Result: In total, 16,196 enteric LTCF outbreaks were reported to NORS and/or CaliciNet from August 2015 – July 2025, of which 12,905 (80%) outbreaks with 342,712 associated cases were attributed to norovirus. The average number of outbreaks reported over 12 months was 1,505 (7,022 total) during the pre-pandemic period, 256 (341 total) during the pandemic period, and 1,085 (3,256 total) during the post-pandemic period. The predominant genotype during these periods, GII.4 Sydney[P16], caused 42% of outbreaks with genotype data available. During the 2024-25 season, 2,286 LTCF norovirus outbreaks were reported (52% higher than the pre-pandemic period) and the predominant genotype (76%) was GII.17[P17]. Outbreak size (median [IQR]: 21 cases [11–35]) and duration (median [IQR]: 8 days [5–14]) were consistent across periods. Hospitalization rates were lowest during the pandemic period (1.8%) and highest during the 2024-25 season (3.2%). Conclusion: The low burden of LTCF norovirus outbreaks during the COVID-19 pandemic highlights the impact of non-pharmaceutical interventions in preventing outbreaks in this setting. The increased norovirus activity in the 2024-25 season associated with a new predominant strain suggests that more proactive laboratory testing in response to outbreaks is needed in this at-risk population to monitor trends in norovirus

Labor-managed firms, whether in the form of worker cooperatives, codetermination, or broad-based employee ownership, have recently prompted substantial public debate, to which political theorists have contributed with normative analyses that are seriously deficient insofar as they have neglected considerations of productive efficiency. I offer a normative view of labor-managed firms that leans squarely on efficiency considerations. I first argue that the value of productive efficiency is grounded not only on the interests of capital suppliers and society at large, but also on workers’ interest in avoiding domination by their bosses, and examine how efficiency may serve and set back this interest. I next argue that some variants of labor-managed firms can secure efficient production while protecting workers’ interest in nondomination more robustly than capital-controlled firms. Finally, I compare labor-managed firms to alternatives to achieve these aims, including self-employment, workplace regulation, unionization, and labor market policies to enhance workers’ exit options.

Background: Many Infectious Diseases (ID) fellowship programs have created antimicrobial stewardship (AS) scholarly tracks to guide burgeoning stewards. However, few programs have reported details of their AS curricula or career outcomes after track completion. We describe the major components of our AS track and the current AS-related faculty roles of prior participants. Methods: In 2015, our ID fellowship program, based at an academic medical center (AMC), formally created an AS track for second-year fellows (typically one fellow per year). The goal is to prepare fellows to become effective AS team members and potentially hold program leadership roles. We annually survey prior track participants regarding their current institution and roles. All current fellows are surveyed annually to evaluate AS-related rotations and conference series using a five-point Likert scale (1=Poor to 5=Excellent). Results: The track emphasizes three major components (Education, Mentorship, and AS Experiences) based on the SHEA White Paper “Guidance for the Knowledge and Skills Required for Antimicrobial Stewardship Leaders” (Cosgrove SE, ICHE 2014) (Figure 1). Early stewardship content education is provided through an annual conference series (“Summer Series”) and an experiential combined AS/Infection Control rotation for first-year fellows; both have demonstrated improved evaluation scores over the past five years (Figure 2). Since 2015, eight fellows have completed the second-year AS track; the majority currently practice at AMCs. Seven (88%; 7/8) currently report dedicated FTE support for AS activities and five (63%; 5/8) hold AS leadership positions as either Medical Director or Associate Medical Director (Table). Conclusion: During the first decade of our AS scholarly track, we developed a structured curriculum emphasizing acquisition of stewardship expertise, mentorship, and diverse experiential training. The majority of AS track fellow graduates continue in stewardship roles as faculty, including leadership positions, suggesting our longitudinal track may support early-career development in AS.

Background: The safety of midlines (MLs) versus peripherally inserted central catheters (PICCs) in the context of outpatient parenteral antimicrobial therapy (OPAT) is still debated. The Infectious Diseases Society of America guidelines currently offer a weak recommendation to consider MLs for antibiotic durations of <14 days. The purpose of this study was to quantify the ML complication rate compared to PICCs for OPAT. Methods: We performed a single-center, retrospective cohort study of MLs and PICCs placed by the bedside vascular access team for OPAT as recommended by the infectious diseases consult service at a 670-bed urban academic medical center. Between July 2019 and June 2022, 1351 catheters were placed in 1252 unique patients for OPAT. The primary exposure was the placement of a ML versus PICC, informed by selection guidelines from the Infusion Nurses Society. The primary outcome was any bloodstream infection (BSI) or superficial or deep venous thromboembolism (VTE) while the catheter was present. We estimated the hazard ratio (HR) of developing the outcome among MLs compared to PICCs using Cox proportional hazards models, accounting for multiple episodes of OPAT-related catheter placement over time in the same patient and adjusting for confounding by planned antibiotic duration of ≥14 days and the use of vancomycin. We tested whether planned antibiotic duration modified the association between catheter type and the outcome using an interaction term. Results Demographic and clinical characteristics are in Table 1. The ML complication rate was 6.1 per 1000 line-days (26 [3 BSI, 23 VTE] of 322 MLs) versus 1.2 per 1000 line-days for PICCs (40 [11 BSI, 30 VTE] of 1029 PICCs), with a higher complication rate for MLs (adjusted HR [aHR] 2.97, 95% confidence interval [CI] 1.32-6.70, p=0.01). Adjusted survival curves are given in Figure 1. The aHR was 0.97 (95% CI 0.30-3.11, p=0.96) among catheters with a planned antibiotic duration of ≤14 days and 4.11 (95% CI 2.08-8.16, p<0.01) for <14 days (p-interaction=0.03). Conclusion In this study of patients receiving OPAT, complications were uncommon but significantly more frequent for MLs than PICCs. This association appeared to differ by planned antibiotic durations of <14 days than ≤14 days. Our study calls into question the safety of MLs for OPAT, especially for prolonged durations of therapy.

Background: Mycobacterium chelonae and other non-tuberculous mycobacteria (NTM) isolated from ice/water dispensers have been implicated in healthcare outbreaks. We present the results of mitigation activities utilized to reduce M. chelonae from ice/water dispensers as part of an outbreak response. Methods: Interventions were performed in phases. Phase 1 involved ensuring compliance with the manufacturer’s ice/water dispenser cleaning protocol for 11 dispensers involved in the outbreak. Phase 2 compared monthly, bi-monthly, and quarterly cleaning outcomes of seven dispensers. Phase 3 evaluated point source controls on four dispensers in a test environment, two with a 0.005 µm microbial filter either solo (single stage) or in combination with a particle filter (two stage) and two with an ozone treatment system (each with a particle filter). In all phases, monthly environmental culturing for NTM was performed from four sources (water before the filter, water after the filter, ice and water from the spout) on each dispenser for four months. Additionally, swab samples of the waterspouts were collected in Phase 1. Several incoming water sources were also assessed for NTM. Identification of NTM from culture was performed by matrix-assisted laser desorption/ionization-time of flight mass spectrometry. Results: Phase 1 revealed one NTM positive sample from an ice/water dispenser in the first month with an increasing number of positive results each subsequent month with 40 /44 samples with NTM including 10 M. chelonae in month four. Phase 2 results did not show a significant difference in NTM results between groups by cleaning frequency. Phase 3 results continued to show positive NTM across all dispensers with the single stage microbial filter outperforming the other point source controls (Figure 1). The hospital incoming water results confirmed the presence of M. chelonae along with other species of NTM. Conclusions: Recovery of NTM including M. chelonae from the incoming water supply highlights the known risk from municipal water. Upon implementation of point source controls, the single stage filter had no NTM recovered from water immediately after the filter which may be beneficial. Despite robust and increased cleaning frequency, NTM was still recovered from all dispensers which suggests the presence of biofilm. Improved cleaning protocols are needed from ice/water dispenser manufacturers to address NTM biofilm issues in healthcare settings. Additionally, national guidance on management of NTM in hospital water systems to reduce risk to vulnerable patient populations is overdue.

Background: Clostridioides difficile is one of the most common healthcare associated infections. Due to diagnostic uncertainty, patients are often treated for colonization instead of infection. Colonization is not believed to be a direct precursor for a Clostridioides difficile infection (CDI) and does not require treatment. The aim of this study is to analyze factors associated with overtreatment for Clostridioides difficile colonization, and whether these factors contribute to recurrence. Methods: This study examined fully abstracted incident Clostridioides difficile cases, defined as the first positive stool test for persons at least one year of age residing in Davidson County, Tennessee from 2018–2022. Colonization was determined by negative enzyme immunoassay test combined with positive polymerase chain reaction test. Overtreatment was defined as receiving treatment for colonization. Recurrence was defined as a positive stool specimen between two to eight weeks of the last positive specimen. Overtreatment and recurrence were analyzed with two separate logistic regression models using SAS 9.4. Results: There were 1,097 patients examined. Of these patients, 61% were overtreated for colonization. Patients without comorbidities and with increasing age had lower odds of overtreatment (OR=0.6, 95% CI [0.4–0.9]; OR=0.7, 95% CI [0.6–0.8]). Patients with hospitalizations on the day of or in the six calendar days after the specimen collection or with diverticulitis or inflammatory bowel disease were significant for higher odds of overtreatment (OR=1.3, 95% CI [1.0–1.8]; OR=1.6, 95% CI [1.1–2.4]; OR=2.1, 95% CI [1.2–3.8]). There was no significance found for predicting overtreatment with other demographics or comorbidities (e.g., diabetes mellitus, chronic kidney disease, chronic pulmonary disease). Increasing age had higher odds of recurrence (OR=1.3, 95% CI [1.0–1.6]). No other factors associated with overtreatment were associated with recurrence. Conclusion: Overtreatment was common in this population. Hospitalization contributed to increased overtreatment of Clostridioides difficile colonization, and it is important to consider patient comorbidities that may present similarly to clinical CDI when considering treatment. Future studies should examine how overtreatment can affect other CDI outcomes and additional evaluation of general prevalence in the population, incidence of CDI, and mortality rates following overtreatment.

Background: Candida auris (C. auris) is an emerging multidrug-resistant fungal pathogen that continues to spread across the United States and remains classified by the Centers for Disease Control and Prevention as an urgent public health threat. Due to its ability to persist on surfaces and spread easily in healthcare settings, early detection and rapid infection control measures are critical to prevent outbreaks. Based on surveillance data, we implemented targeted C. auris screening in 2024 for patients transferred from outside healthcare facilities. After one year, we assessed adherence, positivity, and clinical infection cases to determine our program’s success and identify potential gaps in screening criteria. Methods: All eligible transfer patients received composite axilla/groin swabs on admission that were sent for external laboratory Polymerase Chain Reaction (PCR) testing. Demographic, clinical, and epidemiological factors, including transferring healthcare facility origin and co-colonizing multidrug-resistant organisms (MDROs), were evaluated alongside clinical C. auris infections identified outside of admission screening (e.g., urine, blood, pleural fluid). These were used to compare characteristics between colonized and infected patients and determine whether expanded screening criteria were warranted. All C. auris-positive patients were placed on transmission-based precautions with rapid notifications to unit leadership. Result: Over the first year (Sept 2024–Sept 2025), 1,725 of 1,937 eligible patients were screened (89.1%), with a positivity rate of 1.50% (26 colonized patients). Patient refusal and screening cancellations were infrequent (18 events; 0.06%). An additional 212 eligible patients (11%) were not screened due to operational factors, with no subsequent positive C. auris clinical cultures during hospitalization. Eight additional patients were diagnosed with C. auris infection through clinical cultures. These patients were ineligible for screening as they were not transfers, though most had frequent readmissions to and from outside healthcare facilities. Demographic and clinical characteristics of colonized and infected patients are summarized in Table 1. Conclusion: Our findings demonstrate that a targeted admission screening program for interfacility transfers identified colonized C. auris patients and enabled timely implementation of infection control measures. However, patients with significant outside healthcare exposure who are not interfacility transfers remain high-risk, indicating a gap in our current screening criteria.

Background: Residents living in post-acute and long-term care settings (PALTC) settings are particularly vulnerable to severe infections caused by common respiratory viruses, including COVID-19, influenza, and respiratory syncytial virus (RSV). The Perceived Vulnerability to Disease (PVD) scale has been used to understand general public perceptions of vulnerability to infectious diseases. We adapted the PVD for administration to PALTC residents and their care partners. Here, we describe the perceptions of infectious disease risk among Veterans and their care partners at a large Veterans Affairs (VA) PALTC setting, termed Community Living Centers (CLCs). Methods: From November 2024 to July 2025, we surveyed residents at a 152-bed CLC. Inclusion criteria were CLC residents aged > Results: Out of 81 eligible residents and LARs, 40% (N=32; 6 residents and 26 LARs) completed the survey. Regarding previous infections, 27 (84%), 9 (28%), and 0 (0%) respondents indicated that Veterans had tested positive for COVID-19, influenza, or RSV, respectively, during their CLC stay. No more than 9 (28%) perceived a moderate to high risk of infection with any of the pathogens during the next month (Figure 1). At least 12 (38%) of respondents agreed or strongly agreed with 6 of the 7 items for the Perceived Infectivity subscale of the PVD; at least 15 agreed or strongly agreed with 6 of 8 items for Germ Aversion (Figure 2). Conclusions: Participant responses to the Perceived Infectability and especially Germ Aversion indicated concerns with personal susceptibility to illness and general contamination. The perceived risk specifically to COVID-19, influenza, and RSV was comparatively lower, despite most Veterans having viral respiratory infections during their CLC stay. Although based on a small sample, our findings provide valuable insight about resident and LAR perspectives that can help inform and support infection prevention efforts in PALTC settings.

Background: Intravenous penicillin G is the preferred first-line agent for intrapartum Group B streptococcus prophylaxis; however, many pregnant patients carry unverified penicillin allergy labels. Although approximately 10% of the general population reports a penicillin allergy, only about 1% have a true allergy, and these inaccurate labels often lead to unnecessary use of broader-spectrum antibiotics, highlighting the need for improved allergy verification and de-labeling in obstetric care. Methods: A retrospective chart review was conducted from January 2022 to December 2024 evaluating documented penicillin allergies in pregnant patients who received care and delivered within a state-wide health system. Patients were excluded if they had a penicillin allergy documented during or after the encounter, or if the allergy was identified as an erroneous entry. A study-specific allergy risk assessment was used to stratify patients into no allergy, low risk, moderate-to-high risk, and severe risk categories, using a conservative approach as the true severity of historical reactions could not be definitively verified through retrospective chart review alone. Patients categorized as no allergy were considered eligible for de-labeling. Results: Of 303 birth encounters screened, 285 met inclusion criteria; ten patients with previously removed penicillin allergy labels were excluded from the primary outcome analysis. Among the remaining included encounters, 51 patients (18.5%) were identified as eligible for penicillin allergy de-labeling based on chart review alone. Eligibility was driven by documentation consistent with non-allergic reactions, including intolerance symptoms (5.8%), history of prior penicillin tolerance (10.5%), and reported familial allergy without personal reaction history (2.2%). Referral patterns for allergy evaluation were assessed to identify additional de-labeling opportunities. Only 12 patients were referred to an allergist during pregnancy; however, 11 of these patients underwent penicillin challenge testing and were successfully de-labeled. The high success rate among referred patients highlights frequent mislabeling of penicillin allergies and suggests substantial missed opportunities for broader de-labeling in the obstetric population. Conclusion: Nearly one in five pregnant patients (18.5%) with documented penicillin allergies were eligible for de-labeling based on chart review alone. Low referral rates for allergy evaluation also indicate significant opportunities to expand penicillin allergy testing in obstetric care, further improving antibiotic selection and antimicrobial stewardship.

Healthcare water management programs (WMPs) have historically emphasized the control of Legionella pneumophila, largely due to its established role in Legionnaires’ disease outbreaks. However, healthcare water systems harbor a wide range of opportunistic premise plumbing pathogens (OPPPs), including nontuberculous mycobacteria (NTM), Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, and Burkholderia cepacia complex. These organisms exhibit distinct ecological preferences and persistence mechanisms that vary by system type. In this study, we analyze microbiological testing data from more than 200,000 healthcare-associated water system samples collected since September 2019, comparing pathogen positivity across ice machines, general potable water, and cooling towers. Results demonstrate substantial variability in pathogen positivity by system type, with NTM showing markedly higher positivity in ice machines and potable water systems (relative to traditional indicator organisms). Legionella pneumophila positivity was highest in cooling towers but substantially lower in potable water. These findings indicate that uniform, organism-agnostic surveillance strategies are insufficient and that WMPs must be selectively designed based on system type, exposure route, and patient risk. Adopting site-specific, organism-selective monitoring frameworks may significantly improve infection prevention efforts in healthcare settings.

Background: Clostridioides difficile infection (CDI) is a major healthcare-associated infection. Although guidelines recommend multistep diagnostic algorithms and symptom-based management with contact precautions, diarrhea assessment is subjective and adherence to diagnostic algorithms may be inconsistent in clinical practice, potentially leading to unnecessary testing and prolonged contact precautions. This study aimed to evaluate real-world practices of CDI testing, symptom assessment, and contact precautions in hospitalized patients. Methods: We conducted a retrospective descriptive study using electronic medical record data from January through December 2025 of adult patients (≥18 years) hospitalized for at least 3 days at a university-affiliated tertiary-care hospital in South Korea with a positive Clostridioides difficile nucleic acid amplification test (NAAT). Collected variables included patient demographics, hospital unit, toxin A/B enzyme immunoassay (EIA) results, presence of diarrhea, CDI treatment, duration and reasons for discontinuation of contact precautions, and symptom status at discontinuation. Diarrhea was defined as three or more episodes of watery or loose stool within 24 hours. Cases were classified as clinically relevant CDI if they had (1) a positive NAAT and positive toxin A/B EIA result, regardless of symptoms, or (2) a positive NAAT and negative toxin A/B EIA result with documented diarrhea, consistent with clinical practice. CDI treatment was defined as ≥10 days of oral vancomycin or metronidazole (oral or intravenous). Contact precautions was discontinued after ≥48 hours without diarrhea. Results: A total of 269 NAAT-positive episodes were identified in 214 patients (mean age, 63.5 ± 17.5 years), most from general wards (68.4%). Toxin A/B EIA was performed in 94.8% of episodes, with 21.2% positivity, and 60.6% were classified as clinically relevant CDI. Diarrhea was documented in 61.3% of episodes, whereas contact precautions were implemented in 95.9%, including 36.1% of episodes without diarrhea. CDI treatment was administered in 75.1% of episodes, although only 49.4% of treated episodes had documented diarrhea at treatment initiation. Contact precautions were discontinued in 94.1% of episodes, with a mean duration of 12.0 ± 11.1 days. Symptom improvement was the most common reason for discontinuation (64.8%). The mean interval between the last documented diarrhea episode and contact precaution discontinuation was 7.7 ± 30.3 days, exceeding the guideline-recommended 48-hour diarrhea-free period. Conclusions: Contact precautions were often implemented without documented diarrhea and discontinued later than recommended. These findings indicate limitation of symptom-based CDI management in routine practice and underscore the need for more objective, standardized symptom assessment to support appropriate diagnostic stewardship and contact precautions.

Background: Long-term care facilities (LTCFs) are a leading setting of norovirus acute gastroenteritis (AGE) outbreaks in the United States. While illness from norovirus infection is typically considered mild and self-limiting, residents in LTCFs are especially vulnerable to more severe outcomes such as hospitalization and, in rare instances, death. Norovirus typically spreads rapidly through LTCFs due to the high infectivity of the virus and the congregate nature of these facilities. Despite the high burden of norovirus outbreaks in the U.S., limited data exist in these settings. Our objective was to characterize clusters of AGE likely associated with a norovirus outbreak among LTCF residents in a large cohort of U.S. LTCFs. Methods: We analyzed electronic health records from the PointClickCare (PCC) database of residents in 14,588 LTCFs across 50 states, D.C., and 1 US territory from 2016 through 2023. We identified AGE episodes using ICD-10-CM diagnosis codes and defined AGE clusters as three or more residents of the same facility with AGE episodes within seven days of one another; norovirus-associated AGE clusters were defined as clusters with at least one norovirus or unspecified viral intestinal infection ICD-10-CM code (A08.1, A08.4). Results: From January 1, 2016 through December 31, 2023, there were 306,683 AGE episodes from 10,653 LTCFs. Among these LTCFs, there were 17,852 AGE clusters of 86,687 (29%) episodes; 648 were norovirus-associated AGE clusters comprising 3,548 AGE episodes. The median norovirus-associated AGE cluster size was 4 residents (interquartile range [IQR]) 3-6; maximum=36). The number of norovirus-associated AGE clusters was lowest in June, July, August, September, and October (average of 3 clusters each month) and was highest in February and March (average of 13 clusters each month). The median (IQR) length of norovirus-associated AGE clusters was 9 (6-13) days from the AGE onset of the first resident to the AGE onset of the last resident in the cluster. Norovirus-associated clusters occurred in 492 facilities: 141 (29%) facilities of <100 residents, 288 (58%) facilities of 100-199 residents, and 63 (13%) facilities of 200+ residents. Conclusions: AGE episodes were commonly reported among LTCF residents in PCC, and approximately 30% were associated with an AGE cluster. Norovirus-associated AGE clusters ranged in size, occurred in all sizes of facilities, and were more common in winter months. Identifying individual-level and facility-level risk factors for norovirus-associated AGE is a next step to inform prevention efforts, including infection control measures and target populations for future norovirus vaccines.

Background. Clinical identification of measles prompts post-exposure prophylaxis (PEP) and surveillance. This report informs on implementation, results, facilitators and challenges associated with two measles post-exposure investigations (MPEI). Methods. Two MPEI were conducted in 2025 at a 545-bed public NYC Health+Hospitals. Measles case evaluations utilized the Identify-Isolate-Inform (I3) tool and the MPEI employed Identify-Inform-Initiate PEP-Isolate process (I4). Measles exposure was defined as a person in the Emergency Department (ED) within two hours of the index case. PEP for non-immune exposures was MMR vaccination within 72 hours (immunocompetent), measles intravenous immunoglobulin (IVIG) within six days (pregnant, immunocompromised), or notification to self-isolate for a 21- to 28-day surveillance period for non-immune persons who did not receive PEP. The exposure window was defined after security tape reviews of ED index-case entries. Epic (Verona, WI) facilitated exposure recalls; a ‘Measles rule out’ banner was uploaded to each chart. Internal and external stakeholders were informed after suspected case isolation. Recalls were conducted using standardized scripts tailored to initial responses and identified accompanying persons. MMR vaccination status was screened for in Epic and NYC vaccine registry. Descriptive analyses were calculated for MPEI. Results. Case 1 presented in Spring 2025 with airborne infection isolation room (AIIR) placement within 16 minutes. Case 2 presented in Summer 2025 with AIIR placement within 10 minutes. Each case had measles serology and nasopharyngeal swab for PCR obtained; the NYC Public Health Laboratory confirmed measles for Case 1 and Case 2 at 28- and 11-hours post-presentation, respectively. There were 145 adults and one child identified in the two MPEI. Spring MPEI identified 70 patients, 11 accompanied persons, 34 staff; Summer MPEI identified 22 patients, three accompanied persons, six staff. Fifty-nine of 146 (40%) exposures were measles immune, 30 received MMR, 3 non-immune pregnant women and one immunocompromised host received measles IVIG; 53 persons were notified to self-isolate through the surveillance period. No secondary cases of measles were identified. Discussion. Each MPEI was initiated after astute identification of a measles case. Key MPEI facilitators were an existing I3 preparedness plan and prior trainings, rapidly defined epidemiological exposure windows, leveraged use of Epic, and a structured post-exposure I4 process. Major challenges were related to uncertainty of a potential surge of cases requiring internal communications for patient flow during the recall process and for streamlined bidirectional communication with public health agencies. We acknowledge limitations of a single-site study and inherent biases of retrospective study design.

Background: Approximately one in ten US children report an allergy to antibiotics. However, ~95% of these pediatric allergy labels are inaccurate upon evaluation. Inaccurate allergy labels lead to suboptimal antibiotic prescribing, increasing patients’ risk of treatment failure and adverse effects. Successfully removing inaccurate pediatric allergy labels (i.e., delabeling) requires engagement from primary caregivers. This study examined caregiver (e.g., parents, stepparents) perceptions and attitudes toward delabeling in pediatric care. Methods: We invited US adults to an online survey about antibiotics (March-April, 2024). Respondents identifying as a primary caregiver for a child with an antibiotic allergy answered questions about the child’s allergy (e.g., type, severity), their willingness to try methods to assess whether the child was non-allergic (oral medication vs. skin-scratch challenge), and their anticipated reaction to a negative skin-scratch test result for the child (i.e., indicating no allergy). Results: Table 1 shows characteristics of the 37 caregivers of a child with an antibiotic allergy, 31 described the child’s allergies as mild/moderate (83.8%), 5 as severe (13.5%), and 1 as life-threatening (2.7%). Penicillin was the most common allergy (27 of 37 [73.0%]). More caregivers were willing to try skin-scratch testing (33 of 37 [89.2%]) than were willing to try oral challenge (26 of 37 [70.3%], p=.02). Yet, 21.6% of caregivers (n=8) would not accept the results of a negative skin-scratch test for the child and 29.7% (n=11) would not agree to remove the allergy from the child’s medical record based on that test. Almost all caregivers (35 of 37 [94.6%]) said they would try to re-add the child’s allergy onto their medical record if removed following a negative skin-scratch test. Caregivers listed various concerns about delabeling in free-text boxes including fear of harm or distress to the child, negative past experiences, distrust of clinicians, and belief that, as caregivers, they know the child best and should not knowingly do something that could harm them. Other concerns included keeping allergy labels as a safety net, worrying allergies could return, and preferring to be ‘safe than sorry’. Conclusions: In this survey of US adults, caregivers of children with self-reported antibiotic allergies expressed hesitancy toward delabeling efforts. Findings suggest increased testing efforts alone are likely insufficient as caregiver attitudes may present a major barrier to effective antibiotic allergy delabeling in pediatric care. Strategies for addressing caregiver concerns that persist after negative test results are needed to ensure safe, guideline-concordant antibiotic prescribing through childhood and beyond.

Background:?It is unclear how antibiotic stewardship programs can effectively address antibiotic overuse at hospital discharge. A recent stepped-wedge cluster-randomized clinical trial evaluated the effectiveness of performing prospective audit-and-feedback on patients as they approached hospital discharge. In this study, we assessed barriers and facilitators to performing this intervention during the clinical trial. Methods: We performed a qualitative study using semi-structured interviews across ten acute-care hospitals participating in the trial, including three Veteran’s Health Administration (VA) hospitals, two academic medical centers and five community hospitals (Table 1). We created a semi-structured interview guide based on the RE-AIM framework to focus on perceptions of implementing the intervention. We interviewed 14 antibiotic stewardship personnel. All interviews were audio recorded, transcribed, and coded in a three-person team. Using thematic analysis, codes were developed and collapsed into themes. Results: Half of the intervention sites struggled to identify patients at discharge, limiting the stewardships teams’ ability to conduct prospective audit-and-feedback at discharge (Table 2). In contrast, strong provider-stewardship relationships and existing hospital initiatives, such as handshake stewardship and discharge rounds, facilitated implementation of the intervention (Table 3). Stewardship teams at four sites also reported challenges guiding antibiotic use for patients who had formal Infectious Disease consults, as prescribers typically preferred to follow the documented recommendations from the ID team. Conclusions: Our findings underscore the importance of accounting for the hospital and organizational context when implementing discharge-focused audit-and-feedback interventions, paying particular attention to existing policies, procedures, and the dynamics between antibiotic stewardship teams and front-line prescribers.

Background: Contact precautions were used during COVID-19 to reduce nosocomial transmission, though these practices have environmental impacts. We sought to examine the effect of de-implementing contact precautions in a regional healthcare system. Methods: We utilized the electronic medical record to identify all hospital-onset COVID-19 cases among hospitalized patients in nine regional hospitals from Results: There were 88,963 patient-days of isolation during implementation, and 23,378 patient-days of isolation after implementation. Conclusions: Despite de-implementing glove/gown use, we observed no increase in HO COVID-19; however, we benefited from a considerable decrease in both global warming potential and waste.