Background: The Centers for Medicare & Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP) assigns penalties to the worst-performing quartile of U.S. hospitals based on the Patient Safety and Adverse Events Composite (PSI-90) and five standardized infection ratios (SIRs). Although these measures are weighted equally in program scoring, the extent to which each metric contributes to penalty risk is unclear. Understanding the relative influence of these measures is essential for infection preventionists (IPs) and quality leaders working to anticipate penalties and prioritize improvement efforts. Methods: We conducted a retrospective cross-sectional analysis of 3,082 acute care hospitals included in the CMS Fiscal Year (FY) 2025 HACRP dataset. Predictors included PSI-90 and SIRs for central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI), Clostridioides difficile infection (CDI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. All measures were analyzed as continuous variables and standardized using z-scores. Multivariable logistic regression estimated associations with penalty status. Model discrimination was assessed using area under the curve (AUC). Results: All six measures were strongly associated with HACRP penalties. PSI-90 demonstrated the largest effect size (OR 10.87; 95% CI: 7.76–15.7). Among infection-specific measures, CAUTI (OR 8.60; 95% CI: 6.27–12.1) and CDI (OR 8.48; 95% CI: 6.25–11.8) showed the strongest associations. The primary model exhibited excellent discrimination (AUC = 0.99). Distribution plots revealed that penalized hospitals consistently had higher PSI-90 and SIR values; for CAUTI and CDI, even small shifts toward or above an SIR of 1.0 increased penalty likelihood. Conclusions: In FY2025, PSI-90 demonstrated the strongest association with HACRP penalty assignment, despite equal weighting with infection-specific SIRs. Among infection measures, CAUTI and CDI showed the greatest influence on penalty risk. These findings provide actionable benchmarks for IPs and quality leaders to interpret performance and anticipate penalty risk within HACRP.

The Korean National Pension Fund is projected to be depleted within thirty years. This paper examines whether short-term economic fluctuations affect fund projections and whether raising the target return can delay fund depletion. Using Vector Auto-Regression analysis, we find that contributions and returns are highly responsive to short-run fluctuations. However, business cycle volatility has a limited effect on fund forecasts. Our simulations suggest that increasing expected returns by taking on more risk can help delay depletion, even when accounting for increased volatility.

Background: A substantial proportion of outpatient antibiotic prescriptions exceed guideline-recommended durations. Although most antibiotic use is in the outpatient setting, the majority of antimicrobial stewardship efforts focus on inpatient care. Prior studies suggest that modifying electronic order defaults is a low-burden strategy to nudge prescribers toward shorter, guideline-concordant courses. We evaluated the impact of updating default durations and adding selectable “speed buttons” to electronic orders for commonly prescribed outpatient antibiotics. Methods: We conducted a retrospective pre–post analysis comparing outpatient antibiotic prescriptions during a pre-intervention period (July 1–October 31, 2024) and post-intervention period (July 1–October 31, 2025). Only prescriptions with durations of 1–14 days were included. In June 2025, an electronic order redesign was implemented for the 13 most frequently prescribed outpatient antibiotics, incorporating updated default durations and short-course speed buttons based on guideline-supported treatment ranges for common outpatient infections (Table 1). The primary outcome was the change in proportion of prescriptions aligning with the new default duration. The secondary outcome was the change in mean prescribed duration for each antibiotic. Results: There were 80,669 pre-intervention and 86,895 post-intervention prescriptions. All antibiotics except amoxicillin demonstrated an increase in prescriptions aligning with the new default duration (Figure 1A), and all increases were statistically significant except for cefadroxil. The largest increases were observed for cefpodoxime (18.2%) and nitrofurantoin (16.7%). For cefadroxil, the largest absolute shift was a reduction in 10-day courses, decreasing by 10.9% (p<0.001). Amoxicillin defaults remained 10 days in both periods, with new 5-, 7-, and 10-day speed buttons added. Five-day amoxicillin courses increased by 5.5% (p<0.001), representing the largest shift in amoxicillin prescribing. Statistically significant differences in mean prescribed duration were observed for most antibiotics, with small absolute reductions noted (Figure 1B). The largest absolute reductions in mean duration were observed for cefadroxil (−0.82 days) and cefpodoxime (−0.64 days). No significant change was observed for cephalexin, cefdinir, or metronidazole. Cephalexin and metronidazole lacked pre-intervention default durations. Conclusions: The addition of short-course speed buttons and updated default durations impacted the length of outpatient antibiotic prescriptions. The intervention increased alignment with guideline-consistent durations and resulted in consistent reductions in mean prescribed duration across most agents. These findings suggest that simple, low-burden changes to electronic antibiotic order design can effectively influence antibiotic prescribing patterns.

Background: Hospitalized patients colonized or infected with multidrug-resistant organisms (MRO) have historically been placed on contact precautions (CP) for months or indefinitely. However, the necessity of CP for MROs to prevent nosocomial transmission is controversial, and adult data show that standard precautions might suffice for select MROs. Data in pediatrics are lacking, and isolation practices vary between institutions. After literature review and benchmarking with peer institutions, we sought to decrease the amount of time patients in our institution with MROs spent on CP. We aimed to decrease the proportion of inpatient days on CP for patients with MROs while maintaining or decreasing the rate of healthcare associated (HA)-MROs. Methods: Between -12/, we completed a series of plan-do-study-act cycles. These included (1) major MRO policy update with new de-isolation criteria (Table 1), (2) frontline provider education, and (3) implementation of a secondary clinical review by infection prevention and control (IP&C) medical director, to appropriately expedite the removal of undue isolation of patients with MRO infection status. Eventually, infection preventionists no longer needed a secondary review, so the fourth PDSA cycle eliminated that secondary review. Our outcome measure was proportion of inpatient days in CP for patients with MROs. Our process measure was the number of medical director case reviews/month; balancing measure was number of total HA-MRO, HA resistant gram-negative rods (GNR) and HA Methicillin-resistant Staphylococcus aureus (MRSA)/month. Data were monitored on statistical process control charts. Results: Proportion of MRO isolation days decreased from 4.5% to 2.6% (figure 1). Number of medical director secondary reviews increased and was sustained for 8-months until no longer required (figure 2). No center line shifts were noted in the?rate of HA-MROs (figure 3). Conclusion: Shortening the duration of CP for select MROs can be safely implemented and did not increase HA-MDRO rate in our children’s hospital.

Background: Contaminated endoscopes are a recognized source of nosocomial transmission of infection. Endoscope-associated Salmonella transmission was once common, however, as a result of stringent reprocessing guidelines, including high-level disinfection, a 2018 review indicated that no cases were reported since 1987. Methods: In July 2024, the Illinois Department of Public Health identified and notified the local health department (LHD) of a cluster of three Salmonella Enteritidis (SE) cases from the same jurisdiction that were related by whole genome sequencing (WGS). The LHD investigated the cluster, as well as other Salmonella cases that were pending WGS, to identify a common source. The investigation included case interviews, interviews of patients with a common exposure, medical record reviews, isolate serotyping and whole genome sequencing (WGS), scope culture, and site visits for Infection Control Assessment and Recommendations (ICAR). Results: Index case reported symptoms including fever, nausea, vomiting, and urgent diarrhea. Two weeks prior to symptom onset, the case-patient had an esophagogastroduodenoscopy (EGD) and colonoscopy at an outpatient gastroenterology and endoscopy center. 56 patients had EGDs performed with the same scope, 48 of whom were interviewed regarding gastrointestinal symptoms post procedure. Six patients reported experiencing symptoms following their procedure, five of whom were already included in the investigation. The sixth case tested positive for Salmonella Newport and was excluded. Seven total cases of Salmonella were identified as associated with this investigation with illness onset between May 3, 2024, and September 20, 2024. Six were confirmed to be SE and closely related (0 SNPs) by WGS; one specimen was not sent to the state lab for WGS. ICAR identified several opportunities for improvement however there was not a clear gap in the disinfection or other processes that were observed. Namely, the scope passed the facility’s leak test. Scope culture was negative for Salmonella and other gram-negative organisms. The scope was sent to a third-party endoscope repair company; it did not pass their leak test, and the scope was refurbished. The facility planned to prospectively have all scopes inspected routinely. Staff was also retrained by the consultant company on reprocessing procedures. Conclusion: Scope-associated Salmonella transmission may be rare, but it is not entirely bygone. Cases may be under-reported if symptoms are attributed to the procedure itself or the underlying condition which prompted the procedure or are self-resolving and do not lead to diagnosis. Because scopes are complex in design and require fidelity to strict reprocessing, prospective maintenance routines, and re-training and auditing of reprocessing processes may be prudent.

Background: As of 2024, sexually transmitted infections (STI) cases remain 13% higher than they were a decade ago. Budget cuts affected 61.5% of local health department STD clinics, with 14.1% reducing clinic hours. Between 2008-2010 and 2011-2013, STI-related Emergency Department (ED) visits increased by 38.6% compared to 2% for all diagnoses. Reduced public STI funding and services have increased ED utilization. This study examined associations between social determinants of health (SDOH) and STI-related ED utilization. Methods: This retrospective cross-sectional study analyzed data from ED-based STI testing at three urban hospitals in Northwest Indiana between January 2021-March 2025. The dependent variable was STI-related ED visit. Independent variables were demographics, SDOH, behavioral, and health outcomes. Descriptive, bivariate (Chi-Square, Mann-Whitney U, Kruskal Wallis; p<0.05) and multivariate (Binary Logistic Regression; p<0.05) analyses were conducted using SPSS v31.0. Results: Conclusions: Specific SDOH are associated with STI-related ED utilization. Improving funding of publicly funded STI clinics can help to reduce healthcare costs and barriers disproportionately affecting marginalized patient populations. Future efforts should focus on strengthening ED-based SDOH screenings and referrals which may support efforts to redirect patients to cost-effective healthcare settings (e.g., public STI clinics), improving outcomes and reducing system burden.

Introduction: Outpatient parenteral antimicrobial therapy (OPAT) allows patients to receive intravenous antibiotics safely outside the hospital and is an important strategy to reduce inpatient hospital stays, healthcare costs, and exposure to nosocomial pathogens. However, OPAT carries risks, including adverse drug events, repeat healthcare encounters, and treatment complications. Prior studies suggest certain populations such as Black/African American patients may be at higher risk for adverse outcomes, underscoring the need to evaluate OPAT program performance. We aimed to characterize clinical outcomes among patients enrolled in the Loyola University Medical Center (LUMC) OPAT program and identify factors associated with adverse events. Methods: We conducted a retrospective case-control study of adults enrolled in the LUMC OPAT program between 10/01/24 – 12/31/24. Patients were identified through OPAT flowsheets, a specialized Epic flowsheet created to follow patients enrolled in OPAT. Inclusion criteria were age ?18 years and completion of OPAT at LUMC. Patients who did not complete OPAT at LUMC, lacked documentation, or followed with non-LUMC ID were excluded. Cases were defined as those who suffered an OPAT complication, defined as any of the following: 30-day OPAT or infection related ER visit and hospital admissions, medication adverse events, and vascular access complications. Controls were patients who did not have an OPAT complication. Data collected encompassed patient demographics, comorbidities, and OPAT related clinical characteristics. Univariable and multivariable analysis was conducted using R, statistical significance set to p<0.05. Results: Of 97 patients identified, 74 met the inclusion criteria (Figure 1). 27 (36%) experienced an OPAT complication (Table 1). OPAT complications were more common in patients who were younger (median age 52 vs 64 years, p<0.01) and receiving OPAT at home (63% vs 32%, p=0.04). In multivariable analysis, younger age, and non-English speaking status were strongly associated with OPAT complications. Conclusion: Younger age and non-English speaking status were significantly associated with OPAT complications. Receiving OPAT at home demonstrated a trend toward increased risk. Race, ethnicity, zip code, insurance status, and underlying comorbidities were not associated with complications. Microorganism and vascular access type did not differ significantly between groups. A larger study is planned to confirm associations identified from this study, and to develop interventions to help improve outcomes for at-risk populations.

Background: Antibiotic allergy labels are common in clinical practice but rarely represent true IgE-mediated allergies. Mislabeling leads to increased utilization of broad-spectrum antibiotics, rates of Clostridioides difficile infection, drug toxicities, and healthcare costs. National societies recommend systematic confirmation of patient-reported antibiotic allergies as a core antibiotic stewardship activity, but risk-stratification tools remain under-utilized. We sought to assess the perceptions of antibiotic allergies in hospital passersby and stratify those at risk of true antibiotic allergy to encourage discussions on de-labeling or additional testing with appropriate healthcare providers and to ultimately optimize antibiotic use. Methods: During World Antibiotic Awareness Week 2025, a RedCap survey was offered to hospital passersby at Virginia Commonwealth University Medical Center over a 4-hour period. Surveys were completed on electronic tablets in the presence of healthcare providers. Validated decision tools (PEN-FAST, CEPH-FAST, and SULF-FAST) were used to stratify patients based on their risk of true antibiotic allergies. Scores of 0 indicate very low (<1%) risk of a positive antibiotic allergy test; scores of 1–2 indicate low (5%) risk; and scores of 3 indicate moderate (20%) risk. Responses were analyzed using descriptive statistics. Result: Eighty-four participants, spanning 8 to 81 years old and 68% of them female, completed the RedCap survey. Of those, 48 (57.1%) unique participants reported at least one allergy. The most common allergy reported was penicillin (34/48), followed by sulfa drugs (19/48) and cephalosporins (12/48). Of the 48 participants, 12/48 (25%) scored 0 on all applicable risk-stratification tests, indicating a very low risk for allergy. They were encouraged to discuss prompt antibiotic allergy de-labeling with their primary care provider following a risk-benefit discussion. A total of 18/48 (37.5%) participants on all applicable risk stratification tests scored 1 or 2, indicating a low risk for allergy. They were encouraged to seek referral to a specialist for allergy testing and likely antibiotic allergy de-labeling. The remaining participants who scored 3 or more indicating moderate to severe risk were not recommended for antibiotic allergy de-labeling. Conclusion: In passersby of a large tertiary care hospital, our findings showed a high proportion (30/48, 62.5%) of those self-reporting antibiotic allergies are at very-low- to low-risk for a true IgE-mediated allergy. This suggests an opportunity for methodical confirmation and implementation of antibiotic risk stratification in healthcare settings to ultimately improve stewardship of our antibiotic allergy labels. Healthcare providers must be empowered to become frontline stewards of antibiotic allergy labels to optimize prescribing patterns, promote appropriate antibiotic use, and ultimately improve patient care.

Background: A limitation of National Healthcare Safety Network’s (NHSN) Standardized Antimicrobial Administration Ratio (SAAR) is incorporation of only facility and location-level characteristics in predictive antimicrobial use (AU) models (Table 1). Facilities with more medically complex patients may question SAAR’s applicability to their facilities due to lack of patient-level characteristics in predictive models. Case-mix index (CMI), a weighted average of a facility’s patient acuity, could be a marker of patient-level severity for comparison purposes. We investigated differences in SAAR values between facilities with different CMIs. Methods: We stratified Pennsylvania acute care hospitals (ACH) by CMI to compare median SAAR values between hospitals within each CMI quartile. We used 2024 SAAR values from adult inpatient locations using NHSN’s 2017 baseline predictive models. For CMI, we used Centers for Medicare and Medicaid Service’s (CMS) 2024 Diagnosis-Related Group at the hospital CMS Certification Number (CCN[KK1] ) level. CMI is defined at the CCN level while AU is reported under multiple NHSN organization IDs (orgIDs); therefore, observed and predicted antimicrobial days were summed across all orgIDs within each CCN to generate a single CCN-level SAAR for Adult All-Antibacterials. Hospitals were grouped into quartiles based on CMI and median SAAR values were calculated for each group. SAAR differences across CMI quartiles were assessed using the Kruskal–Wallis test. Result: Among 112 Pennsylvania CCN-level ACHs with complete AU and CMI data, hospitals were evenly distributed across CMI quartiles (N = 28 each; CMI range 1.26–2.88). Median SAAR values were similar across quartiles (Q1=0.96, Q2=0.97, Q3=0.92, Q4=0.92). SAAR did not differ significantly across quartiles (Kruskal–Wallis χ² = 1.94, p = 0.58). Boxplots showed substantial overlap in SAAR distributions across quartiles (Figure 1). Conclusion Median SAAR values did not differ significantly across CMI groups. Facilities serving more medically complex patients should not discount the SAAR based on lack of inclusion of patient-level characteristics in the predictive models. More research is needed to clarify if currently included SAAR predictive model variables are adequate proxies for patient acuity and if inclusion of additional patient-level factors would produce more accurate predictions. Our CMI dataset only included publicly available Medicare data, which may limit generalizability across age groups

Background: Stenotrophomonas maltophilia isolated from urine cultures often reflects colonization, however true urinary tract infection (UTI) can occur. At Massachusetts General Hospital, antimicrobial susceptibility testing (AST) is routinely performed on urinary S. maltophilia isolates when present in at least moderate amounts or is the predominating organism from a non-sterile culture source. We evaluated patients with S. maltophilia urinary isolates to characterize treatment practices, determine the proportion of isolates representing definitive UTI, and assess recurrence by treatment status to evaluate whether limiting routine AST could reduce laboratory workload and avoid unnecessary antibiotic prescribing. Methods: We performed a retrospective cohort study of patients with positive urine cultures containing S. maltophilia between May 1, 2021 and May 1, 2024. Patients were excluded if they were treated for asymptomatic bacteriuria due to pregnancy or an upcoming urologic procedure, had a repeat urine S. maltophilia isolate within 14 days of index culture, had concomitant systemic infection treated with an antibiotic active against S. maltophilia, or died before recurrence evaluation. The primary objective was to characterize treatment decisions when S. maltophilia was isolated in urine culture. Secondary objectives included determining the frequency of true S. maltophilia UTI and evaluating recurrence based on whether the infection was treated. We defined definitive UTI as localized urinary symptoms with pyuria; possible UTI as systemic symptoms not explained by other causes or localized symptoms with an alternative etiology, with pyuria; and unlikely UTI as no symptoms reported or documented with or without pyuria. Results: A total of S. maltophilia directed therapy, despite only 19 (15.6%) meeting criteria for definitive UTI. In 11 cases, treatment was administered despite UTI being classified as unlikely. Among total untreated urine cultures (n=83) and definitive infections that were untreated (n=7), recurrent S. maltophilia infection was uncommon (3.6% and 0%, respectively). Conclusion: In our cohort, few urinary S. maltophilia isolates were reflective of definitive UTI, and withholding targeted therapy was associated with low recurrence. These findings suggest many isolates reflect colonization, particularly in patients with urinary instrumentation, and support consideration of a more selective approach to AST and antibiotic prescribing when isolated in urine culture.

Background: Prosthetic joint infection (PJI) is a serious complication of joint arthroplasty, typically requiring both surgical management and prolonged antimicrobial therapy which has historically been administered via outpatient parenteral antibiotics (OPAT). Recent studies have shown that oral (PO) antibiotics are non-inferior to intravenous (IV) antibiotics in the treatment for PJI and result in fewer catheter related complications. We aimed to examine the impact of a pilot institutional PJI guideline designed to encourage the use of PO antibiotics for PJI treatment on provider ordering practices at a specialty orthopedic hospital. Methods: In November 2024, our antimicrobial stewardship committee created and published institutional PJI guidelines which outlined appropriate use of PO antibiotics for PJI. Concurrently, we educated Infectious Diseases (ID) providers who practiced at the hospital. We identified all patients who had an ICD-10 code for prosthetic joint infection (T84.5) in the 12 months pre- (November 2023 – October 2024) and post- (November 2024 – October 2025) guideline implementation. Antibiotic days of therapy (DOT) were defined as the number of days where a patient received 1 or more antibiotics on a given calendar day. Primary outcomes were proportion of patients with OPAT orders and number of Peripherally Inserted Central Cathter (PICC) lines placed. Chi-squared (or when indicated, Fisher’s exact) tests examined proportions of patients who had OPAT orders placed and PICC line orders placed in the pre-guideline period compared with the post-guideline period. Student t-tests compared means for length of stay (LOS), outpatient IV and PO DOT in the pre-guideline period compared to the post-guideline period. Results: There were 82 PJI cases identified in the pre-intervention period and 94 in the post-intervention period. There were no differences in the number of OPAT orders placed (30 v. 45, p=0.25), proportion of PICC lines placed [37 (SD 45.1%) v 43 (SD 45.7%), p = 0.25] and mean LOS [5.9 (SD 4.2) v. 6.2 (SD 4.0), p = 0.68] between pre- and post-intervention periods (Table) Outpatient IV DOT [22.5 (SD 58.0) v 22.8 (SD 42.1), p=0.97) and outpatient PO DOT [25.6 (SD 52.9) v 28.0 (SD 35.7), p=0.73) did not significantly change between pre- and post-intervention periods. Conclusions: At a specialty orthopedic hospital, implementation of pilot guidelines for PJI was not sufficient to change ID provider ordering practices for PJI treatment. Future work will evaluate the utility of individualized feedback to increase appropriate use of PO antibiotics for PJI.

Background: Seasonal viral respiratory pathogens increase isolation needs in pediatric care, creating workflow challenges. A survey found variation in isolation guidelines, particularly regarding duration. In Phase 1, we focused on aligning isolation orders, signage, and infection prevention auditing time. In Phase 2, we sought to implement a nurse-led de-isolation process, empowering nurses to evaluate symptoms and determine readiness to discontinue isolation precautions. Methods: An interdisciplinary quality improvement team mapped isolation work processes, identifying 7 decision points for initiating or discontinuing isolation. Using a prioritization matrix, we developed an EMR-integrated, nurse-driven de-isolation tool (figure 1) that generated a nursing task every 7-28 days based on patient status due to protracted illness (e.g., immunocompromised, severely immunocompromised, or neonates). Predefined clinical criteria guided assessments, triggering discontinuation when met, and eliminating clinician intervention. Patients on Extracorporeal Membrane Oxygenation (ECMO) were excluded. We used iterative cycles of testing and refinement to continuously improve the automation process and clarify response options. Outcome measures included successful discontinuation of isolation precautions; process measures surveyed for nursing satisfaction and assessed appropriateness of decisions based on IPC audits; and balancing measures monitored hospital-acquired viral respiratory infections. Data from a 6-month period were analyzed using descriptive statistics. Results: Before implementation, 39 nurses tested the tool. The majority reported satisfaction with its ease of use, clarity of clinical definitions, and appropriateness of assessment outcomes. Completion time ranged from 20 seconds to 5 minutes. 310 nursing assessments were analyzed; 34% discontinued isolation precautions, 50% maintained precautions with discussion during rounds, and the remainder involved patients automatically retained in isolation due to their special status (neonates, immunocompromised) (Table 1). We identified that 72 assessments during the refinement process misfired without an active isolation order. Then, among the 238 assessments with order and assessment dates, the median time between order placement and nursing assessment was 7 days, with an average of 10 days. Most assessments occurred within 14 days for patients without protracted illness status. Over time, the proportion of patients with protracted illness status increased (Figure 2). No clusters of hospital-acquired viral infections were observed, and IP audits confirmed agreement with the nurses’ assessment in most cases. Conclusion: In this phase, we revealed that a nurse-driven, patient-tailored de-isolation process created a systematic approach to remove isolation without increasing exposure risk. Future opportunities entail strengthening congruency between IP and nursing assessment and de-isolation decisions for patients with underlying clinical conditions who may have a more protracted illness.

Background: Extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales are antimicrobial resistant pathogens which cause difficult-to-treat infections. In April 2025, Hospital A notified the Indiana Department of Health about an outbreak of ESBL-Klebsiella pneumoniae. CDC assisted with identifying the sources of the outbreak and recommending control measures. Methods: We defined confirmed cases as ESBL-producing K. pneumoniae multi-locus sequence type (ST) 661 (or closely related ST) by whole genome sequencing (WGS). Suspect cases included 3rd- and 4th-generation cephalosporin-resistant K. pneumoniae without WGS data. All isolates originated from patient cultures collected on or after January 1, 2025, from Hospital A’s network of hospitals and outpatient clinics. An incident case was the first case identified from a patient. Among confirmed incident cases, we abstracted medical charts for 30 randomly selected patients. We assessed infection prevention and control (IPC) practices and sampled the hospital environment to identify potential reservoirs. Results: We identified 70 confirmed and 52 suspect incident cases between January and September. Median patient age was 70 years (range: 19–91 years); 67 (55%) were female. Within 90 days before incident case collection, 28 of the patients with charts abstracted (93%) received care at Hospital A; 27 (90%) received radiologic imaging, mostly CT scans (17/30; 57%) and transthoracic echocardiograms (16/30; 53%). We observed gaps in hand hygiene, personal protective equipment usage, and environmental cleaning. ESBL-K. pneumoniae was recovered from 23 environmental samples, including radiology equipment. WGS revealed that these isolates clustered with patient isolates, showing 0-26 pairwise high-quality single nucleotide variants across a 95.73% core genome. Following the implementation of IPC recommendations, the average number of monthly cases was 21% lower compared to the 9 months prior. Conclusions: Our investigation linked the outbreak to gaps in IPC practices and contamination of the healthcare environment, highlighting the often-overlooked role of the environment in the spread of ESBL-producing pathogens.

Background: In February 2024, Prisma Health, a 17-hospital healthcare system, changed the reflex urine culture criteria to ≥10 white blood cells (WBC) and rejecting cultures if ≥10 epithelial squamous cells in urinalysis (previously included leukocyte esterase and nitrites). In May 2025, we added verbiage to the Epic orderable emphasizing the criteria. Methods: Using the EMR, lists of urinalyses were generated before the reflex criteria change (August 2023, n=229), after (March 2024, n=102), and an additional data pull June/July 2025 to identify patients who had urinalyses done, and to further identify those who had rejected cultures based on the reflex criteria. A subset for pre/post were reviewed, and all patients with rejected cultures were reviewed. Their charts were reviewed and relevant data captured in RedCap databases. Results: Comparing pre-change (n=229) and after (n=102), there was no difference in the two groups for bacteriuria, leukocyte esterase, WBC, nitrites, and epithelial squamous cells (p=0.31). Antimicrobial prescribing was similar between the groups (p=0.17). Out of 24,978 urinalyses with microscopy in June/July 2025, 291 patients had urinalyses that were rejected for cultures (0.012%). Of the 291 patients, 5 were male, 3 nonbinary, and the rest female. Fifty-eight were pregnant persons. Mean body mass index was 32 mg/m2. The top five most common chief complaints were gastrointestinal (n=86), genitourinary (n=46), obstetric (n=41), gynecologic (n=17), musculoskeletal (n=17). For clinician reasoning from note review, most were ordered for suspected urinary tract infection or urinary symptoms (n=134), no rationale documented (n=52), obstetric workup (n=51), metabolic workup (n=16) or sepsis workup (n=16). Ten patients returned to the ED subsequently, but none required additional workup related to their rejected culture. Conclusions: There were no differences between the characteristics of patients between the reflex culture changes. Very few cultures ultimately were rejected due to skin contamination, emphasizing that rejecting samples for culture is a viable option to improve diagnostic stewardship. The predominance of female and obese patients with contaminated urinalyses emphasizes additional attention to urine collection techniques. Fifty eight obstetric patients were ordered routine urinalyses, not following the orderset obstetric patients excluded from reflex culturing; providers need to be educated to ensure they follow pathways in place. Improved documentation about symptoms and different uses for urinalysis is is key for interpretation of this test.

Background: Antimicrobial resistance (AMR) among urinary pathogens threatens the effective treatment of urinary tract infections (UTIs) worldwide, but regional surveillance data from Western India remains limited. In this study, we aimed to characterize trends of the most prevalent uropathogens from multiple medical centers in Maharashtra and identify patterns within their AMR profiles. Methods: This is a multicentric international collaborative project using de-identified patient samples collected from multiple healthcare sites in Navi Mumbai. 300 urine samples were collected by our collaborative medical laboratory and processed in accordance with the Clinical and Laboratory Standards Institute (CLSI) guidelines. Across gender and age groups, data was analyzed for the distribution of uropathogens and their AMR patterns. Results: A total of 129 (43%) positive urine cultures were identified including 90 samples from women (69.8%) and 39 from men (30.2%). Gram-negative bacteria were isolated from 116 (89.9%) positive cultures, with a predominance of Escherichia coli (46.6%), Klebsiella pneumoniae (37.9%), and Acinetobacter baumannii (11.2%). E. coli was the most prevalent isolate in ages 19-50 (52%) followed by K. pneumoniae (34.7%). In ages 51-90, K. pneumoniae predominated (43.9%) followed by E. coli (36.6%). Prevalence of A. baumannii was modestly higher than reports from neighboring regions in India. 68.5% of E. coli and 50% of K. pneumoniae isolates showed multi-drug resistance (MDR). E. coli showed the highest resistance to penicillins (94.4%), oral cephalosporins (66.7%), and beta-lactam/beta-lactamase inhibitors (53.7%). K. pneumoniae was most resistant to penicillins (100%), beta-lactam/beta-lactamase inhibitors (91.3%), and fluoroquinolones (50%). Resistance to fluoroquinolones (50%) in both species was lower than reported in previous studies from Western India (70–78%). The highest sensitivities for E. coli and K. pneumoniae were observed with carbapenems (100%, 97.7%), nitrofurantoin (94.4%, 88.6%), and amikacin (94.4%, 86.4%). Conclusion: Our study emphasizes the need for ongoing monitoring of predominant uropathogens and their AMR profiles at the regional level. Demographic differences between the prevalence of E. coli vs K. pneumoniae suggests potential host or exposure factors influencing pathogen distribution, warranting further research. The strong activity of nitrofurantoin supports its continued use as first-line empiric therapy.

This article argues that in asymmetric international relationships, gratitude functions as a technology of disciplinary power through which material assistance is converted into moral indebtedness. Unlike material conditionality, which constrains what subordinate actors can do, gratitude constrains what they can say, claim, and be within the relationship, delegitimizing resistance by recoding it as emotional deviance. Integrating Maussian gift theory, emotional-regime analysis, and speech-act approaches to emotion, the article theorizes a specific causal sequence: material assistance is framed as a morally valorized gift, which generates a debt of gratitude, which prescribes an emotional performance of acknowledgment and deference, which in turn constrains the subordinate actor’s capacity to contest donor authority. Empirically, the argument is developed through a comparative emotional-discursive analysis of two structurally asymmetric alliances: the Soviet-Cuban relationship during the 1962 Missile Crisis and the U.S.-Ukraine relationship (2022–2025). Across both cases, great powers mobilized gratitude as a reactive disciplinary instrument, deployed to reassert authority at moments when influence risked erosion. The article contributes to the emotional turn in IR theory by demonstrating that hierarchy is mostly sustained through emotional regimes that prescribe what subordinate actors must feel, display, and acknowledge.

Background: During the 2024 national shortage of BD BACTEC blood culture bottles, many hospitals implemented ordering restrictions to conserve supplies. While prior studies have evaluated overall blood culture utilization and patient outcomes, less is known about how such restrictions affected the observed epidemiology of bloodstream infections (BSIs) across organism groups. Understanding these effects is important for interpreting surveillance data and anticipating downstream clinical implications during diagnostic supply disruptions. Methods: We conducted an interrupted time series analysis of BSI episodes at two tertiary-care hospitals from June 26, 2023 through June 25, 2025. A systemwide electronic order restriction implemented from June 26, 2024 through December 23, 2024 limited clinicians to one blood culture set per patient every 24 hours. We grouped blood culture results into episodes and categorized by organism group. Outcomes included organism group-specific episode incidence, hospital outcomes (e.g., in-hospital mortality/hospice discharge), and blood culture utilization. We used segmented regression models with Newey-West standard errors to estimate level and slope changes associated with restriction onset and withdrawal. Results: We identified 5,391 BSI episodes among 4,484 patients, with baseline characteristics stable across study periods (Table 1). Organism group incidence, hospital outcomes, and blood culture utilization varied by period (Table 2). During the restriction period, the relative incidence of enterococci, fungi, gram negative rods, and Staphylococcus aureus/lugdunensis increased, while anaerobes, streptococci, coagulase-negative staphylococci/common commensals, and polymicrobial infections decreased (Figure 1). Interrupted time series analyses demonstrated an overall decrease in BSI incidence during the restriction, with declines for gram negative rods, streptococci, coagulase-negative staphylococci/common commensals, and polymicrobial infections (Figure 2). We observed statistical significance only for a 51.7% decrease in streptococci incidence upon restriction onset (P=.04) and a 3.5% per month decrease in gram negative rod incidence during restriction (P=.02) (Table 3). Estimates for other organism groups were limited by small numbers of observations, resulting in imprecise effect estimates or potentially artifactual findings. Conclusions Single-set blood culture restriction during the 2024 national supply shortage was associated with changes in the observed epidemiology of BSIs, including an overall decrease in incidence and heterogeneous effects across organism groups. Although interrupted time series analyses for several groups were limited by low power, combined visual and quantitative findings suggest that restrictive diagnostic practices may differentially affect BSI detection by organism type. These findings underscore the need for cautious interpretation of surveillance data during diagnostic disruptions and highlight the importance of resilient diagnostic supply chains and evidence-based mitigation strategies.

Background: Multidrug-resistant organisms (MDROs) are prevalent in skilled nursing facilities (SNFs), but patterns of pathogen movement in these facilities are not well understood. We used genomic surveillance to identify MDRO presence on environmental surfaces, focusing on shared mobile medical equipment (MME) and patient room surfaces, to assess contamination patterns in a skilled nursing facility setting. Methods: We conducted environmental microbiological sampling in an 18-bed floor of a community-based, ventilator-capable SNF over four consecutive days. We collected composite samples of patient room environments and five types of shared MME: glucometers, vital signs carts, shower chairs, shower beds, and patient lifts. The timing and location of each sampling event were recorded. 105 samples were collected, cultured on selective media (for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus species, extended-spectrum ?-lactamase producing Enterobacteriaceae, and multidrug-resistant Acinetobacter species), and presumptive MDRO isolates were MALDI-TOF confirmed and whole genome sequenced. We assessed pairwise genomic relatedness using split-kmer analysis for any MDRO species that was isolated at least twice. We established genomic clusters based on two criteria: the proportion of kmers that matched between isolates (< 0.9) and a single-nucleotide polymorphism (SNP) threshold for each MDRO species based on established literature (e.g., < 7 SNPs). Results: In the 105 samples, four MDROs were detected more than once: vancomycin-resistant Enterococcus faecium (VREfm; N=17), methicillin-resistant Staphylococcus aureus (MRSA; N=9), Klebsiella pneumoniae (KP; N=4), and Acinetobacter baumannii (AB; N=2). To date, MRSA isolates have not been whole genome sequenced and are thus excluded from our results. MDRO detection rates varied across species and sample locations (Table 1). To assess whether these detections indicated pathogen movement, we assessed genomic relatedness (Figure 1) and found: 12 out of 17 VREfm isolates belonged to three multi-isolate clusters of sizes ranging from two to seven isolates; three out of four KP isolates formed a single cluster; while the two AB isolates were unrelated. All four clusters that were detected in the study included isolates collected from shared MME. Three of the four clusters detected involved samples taken in more than one location within the ward, with the largest cluster involving VRE isolates collected from five unique patient rooms and three equipment types stored in a hallway (Figure 1). Conclusions: Our findings suggest that MME may be an important reservoir for MDROs and can facilitate pathogen movement between patient rooms in SNFs. Adequate cleaning of shared MME is necessary to address the risk of fomite-based

Methicillin-resistant Staphylococcus aureus (MRSA) is associated with high morbidity, mortality, and outbreaks in neonatal intensive care units (NICU). For MRSA-colonized patients in the NICU, the Society for Healthcare Epidemiology in America recommends continuing contact isolation until NICU discharge, reflecting limited evidence to support safe discontinuation and recolonization concerns. We evaluated MRSA colonization dynamics in a NICU with an active surveillance program to better inform the evidence base for contact isolation practices. All patients in the 58-bed NICU at UCSF Benioff Children’s Hospital San Francisco undergo weekly or biweekly MRSA culture screening. Colonized patients are placed in single-patient rooms on contact isolation for the duration of their NICU admission and undergo decolonization with intranasal mupirocin and topical mupirocin or chlorhexidine wipes; parents are also offered decolonization. We conducted a retrospective review of MRSA surveillance data from January 1, 2021 through December 31, 2024. A patient colonization episode was defined as one or more consecutive positive screens, with multiple episodes separated by at least one negative screen. Comparisons between patients with single and multiple colonization episodes were performed using the Mann-Whitney U test. Among 2,352 patients screened, 111 (5%) had at least one positive MRSA screen and of these, 80 (72%) had a single positive screen. The median time to first positivity (TFP) was 20 days (interquartile range [IQR]: 6-59) and the median length of stay (LOS) was 65 days (IQR: 24-134). Ninety-three (84%) patients had a single colonization episode and 18 (16%) had multiple colonization episodes (Figure 1). Compared with patients with one colonization episode, patients with multiple colonizations had similar median TFP (18 vs. 21 days; p=0.25), but a longer median LOS (98 vs. 49 days; p<0.01) (Figure 2). Colonized patients were placed on a cumulative 5,180 contact isolation days (median: 26 days per patient, IQR: 12-63 days); of these, 2,543 contact isolation days (49%) were during weeks with a negative screen. In a NICU with active MRSA surveillance, targeted decolonization, and robust horizontal infection prevention practices (e.g. hand hygiene, personal protective equipment, and environmental cleaning), MRSA colonization and recolonization detection was lower than previously reported in the literature. Despite this, contact isolation days accumulated substantially, with almost half of the days occurring during periods of negative surveillance testing. These findings highlight the need for further studies to assess MRSA recolonization risk and optimize the duration of contact isolation in NICU patients, ideally guided by local epidemiology and active surveillance.

Background: The 2025 American Thoracic Society Community-acquired Pneumonia (CAP) guidelines conditionally recommend that patients hospitalized with non-severe CAP who reach clinical stability be treated with <5 days (3 day minimum) of antibiotics. To determine whether hospitals were implementing or planning to implement this recommendation, we surveyed 68 hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). Methods: Hospitals participating in HMS completed an electronic survey in October and November of 2025. Abstractors were asked to answer (with stewardship team input) whether their hospital recommended (or planned to recommend) 3-day antibiotic treatment for any patients with CAP. If yes, they were asked a) which patient subgroups, b) whether their hospital guideline recommended 3 days, and c) what stewardship interventions they had implemented to increase 3-day durations. All hospitals were asked about barriers. Results: All hospitals (68/68) responded to the survey; 21% (14) reported they currently recommend a 3-day duration for at least some patients with CAP; another 18% (12) do not but are planning to. Hospital characteristics by response category are shown in Figure 1. Of hospitals already recommending or planning to recommend a 3-day duration, 31% (8) recommend it (or plan to) in all patients with CAP. Among the 18 hospitals recommending/planning to recommend a 3-day duration for only a subset of patients, commonly stated criteria were: clinical stability (55%), non-severe CAP (33%), or uncomplicated CAP (33%). Most hospitals (79%) recommending a 3-day duration included the 3-day recommendation in their CAP guideline and 71% reported at least one stewardship intervention in place to increase use of 3-day durations (10, education; 3, audit and feedback; 2, pharmacist bundle; 1, orderset; 1, discharge-specific intervention). Commonly reported barriers or reasons for not recommending a 3-day duration included: focus on 5-day duration (31%), resource/time limitation (14%), EHR transition (12%), and inability to recommend a 3-day duration unless the entire healthcare system did (10%). Notably, 7% expressed confusion about IDSA endorsement of the ATS guidelines (IDSA endorsed the <5 day duration but not the viral pneumonia recommendation). Conclusion: Just over a third (38%) of Michigan hospitals currently recommend or plan to recommend a 3-day antibiotic duration for at least some hospitalized patients with CAP. For the remaining 62% of hospitals, continued focus on 5-day duration, standard barriers around stewardship infrastructure, and concerns about existing evidence, safety, and guidance limit enthusiasm for a 3-day duration.