Background: Candida auris is a globally emerging, multidrug-resistant fungal pathogen that causes serious, difficult-to-treat infections in hospitalized patients. C. auris cases in the United States have been linked to receipt of healthcare overseas. Outbreaks have also occurred in New York City, New Jersey, Illinois, Nevada, and California. We provide care to patients from all 50 states and 138 countries and are therefore, at risk for encountering C.auris within our facility. Methods: A case-finding tool was created by Infection Prevention and Control (IPAC) within the electronic medical record (EMR) to identify patients for screening. Inclusion criteria was centric to patients who were admitted in the previous 24 hours with a primary address in a foreign country or in areas of the United States with known C. auris transmission. Patients who are positive for Carbapenamase-producing organisms (CPO) are also included in screening criteria. In 2020, Clinical Microbiology validated a polymerase chain reaction (PCR) test in partnership with the State Health Department and IPAC. In January 2022, IPAC created a protocol that allows IPAC staff to order C. auris screening directly in the EMR utilizing the validated PCR test. The order is paired with communication from IPAC alerting the patient care team that C.auris screening is indicated. Instructions on test collection and information on C. auris are also included in messaging. The patient’s primary nurse then obtains verbal consent from the patient to collect a composite axilla–groin skin swab. Swabs are sent to Clinical Microbiology for testing, and results are reported directly into the EMR. Results: Since the introduction of the nursing protocol in January 2022, 2,660 patients have been identified for C. auris screening through November 2025. Of the 2,660 patients identified for testing, 1,111 patients had screening completed. Two patients tested positive for C. auris on screening. Both patients had prolonged travel to regions with known C. auris transmission. Conclusion: The EMR can be leveraged for early identification and screening of patients at risk of C.auris colonization. Case finding tools, combined with nursing protocols and communication strategies within the EMR can be effectively replicated and modified to respond to emerging infections.

Background: Ventilator-associated events (VAEs) are episodes of respiratory deterioration after stability during mechanical ventilation, posing significant risks for morbidity and mortality. Extremely low birth weight neonates (<750 g), particularly those born at 22–24 weeks gestation, are highly vulnerable. In our Neonatal Intensive Care Unit (NICU), eight VAEs occurred in the previous year, leading to prolonged ventilation, increased infection risk, and higher mortality. Reducing VAEs is essential for improving patient safety, health equity, and family experience while meeting NHSN benchmarks and regulatory goals. Methods: A structured, evidence-based approach was implemented using failure mode effects analysis (FMEA) to identify risk factors and guide interventions. A multidisciplinary team developed a formalized VAE prevention bundle, which included: - Formation of a multidisciplinary task force - Process measures tied to critical clinical tasks - Creation of an EHR tool for real-time compliance monitoring - Staff education and workflow alignment - Cultural engagement initiatives to reinforce best practices Pre- and post-intervention data were collected and analyzed for neonates <750 g per NHSN guidelines. Result: Post-implementation, VAE rates decreased from 9.8 to zero per 1,000 ventilator days, achieving an SIR ?1.0 and meeting national benchmarks. Mortality among extremely low birth weight neonates declined by 60%. Integration of EHR visualization and Power BI dashboards enabled real-time monitoring and sustained compliance. The initiative generated an estimated annual cost savings of $2.1 million through reduced length of stay and infection-related expenses. Conclusion: Structured care bundles, integrated data tools, and multidisciplinary engagement can eliminate VAEs in high-risk neonates. Broader adoption across NICUs could enhance patient safety, reduce healthcare costs, and improve outcomes systemwide. Innovative clinical practice plays a pivotal role in sustaining these improvements through adherence to prevention bundles, leveraging technology for real-time compliance, and fostering a culture of accountability. Standardized frameworks and education strategies can be scaled across institutions for continuous improvement. References Bondarev DJ, Ryan RM, Mukherjee D. (2024). The spectrum of pneumonia among intubated neonates in the neonatal intensive care unit. Journal of Perinatology, 44(9), 1235–1243. https://doi.org/10.1038/s41372-024-01973-9 Niedzwiecka T, Patton D, Walsh S, Moore Z, O'Connor T, Nugent L (2019, October). What are the effects of care bundles on the incidence of ventilator-associated pneumonia in pediatric and neonatal intensive care units? A systematic review. Journal for Specialists in Pediatric Nursing: JSPN. https://pubmed.ncbi.nlm.nih.gov/31332968/

This paper reconceptualizes aesthetic action in John Stuart Mill’s art of life as a distinct, world-regarding action, oriented toward ideals such as justice, beauty, and nobility. While morality is guided by obligations to others and prudence by rationality and the cultivation of virtues, aesthetics concerns the aspirational pursuit of collective human flourishing. Rejecting character-based interpretations, the paper distinguishes aesthetic action by its transformative effect and expressive quality. Though not enforceable, aesthetic ideals expand moral imagination and inspire long-term social progress. Drawing on Mill’s separation between action and character evaluation, the argument clarifies that aesthetic action cannot be reduced to virtue or character. Instead, it completes Mill’s tripartite normative framework by illuminating a third domain that motivates ethical life through nobleness and imagination. Aesthetic action thus becomes essential to understanding Mill’s perfectionist aspiration and his vision of higher happiness.

Background: Antimicrobial resistance in Clostridioides difficile threatens frontline therapies, particularly vancomycin and metronidazole. Rapid genomic screening can flag putative resistance mechanisms, informing infection prevention and stewardship. We present pilot WGS data focused on vancomycin- and metronidazole-associated determinants. Methods A multicenter collection included the University Hospital in Kraków and five long-term care facilities in Małopolska, in 2022-2023. Sixty-six C. difficile strains were sequenced (WGS, AVITI PE300) and analyzed bioinformatically (Genpax IDEM, version 2.6); eight originated from colonized individuals, the remainder from CDI cases. We extracted the prevalence of vancomycin-associated genes (vanR-Cd, vanS-Cd, vanT-Cd, vanG, vanZ1, and vanS-Cd_T369I variant) and the metronidazole-associated gene nimB-Cd. Results Markers linked to vancomycin resistance were frequent: vanR-Cd (93.9%), vanT-Cd (71.2%), vanS-Cd (63.6%), vanG (59.1%), vanZ1 (51.5%), and vanS-Cd_T369I (4.5%). The metronidazole resistance marker nimB-Cd occurred in 95.5% of isolates. Notably, only one strain lacked any vancomycin resistance gene, and this isolate was recovered from a patient with CDI. These pilot genomic findings suggest widespread carriage of loci associated with reduced susceptibility to vancomycin and metronidazole in our regional C. difficile population. Conclusions In this pilot dataset, C. difficile isolates frequently carry genomic elements associated with vancomycin and metronidazole resistance. However, the mere presence of these markers, such as nimB or genes under vanRS regulation, may not independently indicate phenotypic resistance without specific functional mutations or regulatory changes. Phenotypic confirmation remains essential to establish clinical relevance; standardized susceptibility testing and integration of genotypic–phenotypic correlations with clinical data will follow in the next phase. Until then, these preliminary WGS results should be interpreted with caution and primarily guide prioritization of surveillance and stewardship actions.

Background: University Health (UH) Medical Center is a longstanding 238-bed safety net hospital in Kansas City, MO, that uses LabID Event Reporting for Clostridioides difficile infection (CDI), with pre-agreed intuitional testing criteria, and where there was an increase in hospital-onset (HO) CDI in 2024. We sought to examine the factors associated with HO CDI at UH. Methods We conducted a case-control study that included all patients (cases) with a positive polymerase chain reaction (PCR) for toxigenic C. difficile in 2024, on hospital day < 3. We defined HO CDI as positive PCR occurring on hospital day < 3. We matched the cases 1:1, by age and gender, with patients (controls) having a negative PCR for toxigenic C. difficile in 2024, on hospital day < 3. Electronic health record was used to extract data that included demographic and epidemiological variables, Charlson Comorbidity Index (CCI), onset of diarrhea, and timing of stool collection, length of stay, and exposures (within past six months of CDI) to hospitalization, surgery, and/or medications including laxatives, proton-pump inhibitors, immunosuppressants, and antimicrobials. Continuous variables were compared via Mann-Whitney U or t test. Categorical variables were compared using X2 or Fisher’s exact test. Univariate and multivariate logistic regression analyses were performed to assess relationship between dependent and independent variables. Statistical significance was at p< 0.05. Results In 2024, there were 20 cases of HO CDI that were matched in 1:1 ratio with 20 controls. The controls had a higher mean CCI than the cases (5.9 vs 3.5). In univariate logistic regression, eight variables had a p-value < 0.05: CCI; cephalosporin use; specialty consults; infectious disease consult; fever; ICU stay; IV contrast receipt; and liver disease. In a multivariate logistic regression model, adjusted for multicollinearity including just five variables, the CCI (OR = 0.38, p = 0.018), specialty consults (OR = 0.00, p = 0.011), and cephalosporins use (OR = 15.06, p = 0.050) were significant; In a final reduced model (removing consults), only the CCI remained significant (p = 0.023). For each one-unit increase in the index, the odds of being a case decreased by 36% (OR = 0.64). Conclusion Charlson Comorbidity Index was a negative predictor, while cephalosporin use was a positive predictor, of HO CDI at UH. Two-step C. difficile testing and tailored antimicrobial stewardship would help optimize diagnosis and management.

Background Blood cultures obtained in the emergency department (ED) are critical for diagnosing bloodstream infections but are frequently compromised by suboptimal sampling practices, contamination, and delays in transport to the microbiology laboratory. These limitations reduce diagnostic yield and may contribute to inappropriate antibiotic use. We evaluated the impact of a sustained, multicomponent quality-improvement intervention on blood culture quality, diagnostic yield, timeliness of transport to the microbiology laboratory, and time to culture growth. Methods We conducted a retrospective analysis of all blood cultures obtained in the ED of an acute-care hospital between January 2019 and December 2025. The ED treats approximately 85,000 patients annually. A multicomponent intervention was initiated in January 2021 and included repeated staff education, quarterly performance feedback, and workflow optimization. Blood culture transport was transitioned from manual delivery to a pneumatic tube system, and diversion tubes were introduced in January 2023 to decrease contamination. Outcomes included annual uptake of two-set sampling, pathogen detection, and contamination rates. Time from collection to incubation and growth was evaluated before and after the intervention. Trends across years were assessed using a test for linear trend. Results A total of 10,729 blood cultures were analyzed. Adoption of two-set blood culture sampling increased over time, from <3.2% (33/901) in 2019 to 45.9% (904/1,971) in 2025 (p<0.001; Figure 1). Overall, the proportion of blood cultures yielding a pathogen increased during the study period, rising from 6.8% (61/901) in 2019 to 12.2% (240/1,971) in 2025 (p for trend <0.001). Pathogen detection was significantly higher when two blood culture sets were obtained compared with a single set (12.9% [455/3,532] vs 8.8% [634/7,197]; p<0.001). In parallel, contamination rates declined markedly, from 13.9% (130/935) in 2019 to 6.0% (173/2,894) in 2025 (Figure 2). Among positive blood cultures, the distribution shifted over time, with contaminants predominating early and true pathogens predominating during the intervention period. (Figure 3) Timeliness of blood culture handling improved concurrently. Median time from collection to laboratory arrival decreased from 9.4 hours (IQR 2.8–14.9) to 2.3 hours (IQR 1.3–4.0; p<0.001). Concurrently, median time from collection to culture growth decreased from 27.7 hours (IQR 20.4–38.5) to 20.0 hours (IQR 14.6–29.3; p<0.001). Conclusions A sustained, multicomponent quality-improvement intervention in the ED was associated with improved blood culture diagnostic yield, reduced contamination, shorter laboratory processing times, and earlier growth detection. These findings highlight the value of coordinated process optimization to advance diagnostic stewardship and patient safety in high-acuity settings.

Background: Advanced planning and adaptable response strategies are essential for preventing measles transmission in healthcare facilities. Objective: To describe a measles management plan and subsequent modifications in response to a cluster of measles cases. Methods: Drawing on previously published work (doi:10.1017/ice.2025.49), the Infection Prevention and Control (IPAC) team initiated a multi-disciplinary team and developed a measles preparedness plan with the following domains: Guidance and education; early detection and testing; isolation and patient movement; contact tracing and exposure management (Table 1). In October 2025, a patient was admitted during their fifth healthcare encounter and was diagnosed with measles. Two family members were later hospitalized with measles. Delayed recognition of the first case prompted enhancements to our preparedness framework (Table 1). Results: The first case resulted in 539 exposed patients. The second resulted in 87 exposures, and the third resulted in no exposure. Despite the extensive exposure, zero secondary measles were reported. Conclusion: Proactive planning enabled rapid response to our first case and controlled secondary transmission. Despite extensive planning, delayed identification of the first case caused significant exposures. As the cluster unfolded, we refined our plan, resulting in zero exposures from the last patient and zero secondary cases, despite over 850 exposures. These efforts may guide other healthcare facilities in improving their measles preparedness and response.

Background: Influenza infection has been temporally associated with acute cardiovascular events, including myocardial infarction (MI). We evaluated whether laboratory-confirmed influenza infection is disproportionately present among ED patients presenting with acute MI compared with patients presenting with other common acute diagnoses. Methods: We conducted a retrospective cohort study using TriNetX data from the 2024–2025 influenza season. Adult ED patients (<18yrs) presenting with acute MI were compared to patients presenting with mutually exclusive acute diagnoses, including gastroenteritis, urinary tract infection or urolithiasis, appendicitis, pancreatitis, cholecystitis, pulmonary embolism, aortic dissection, and myocarditis or pericarditis. Patients with COVID infection 30 days prior the ED visit were excluded. Influenza positivity during the ED encounter was defined as the outcome. All comparisons were adjusted using 1:1 propensity score matching for demographics, cardiovascular risk factors, chronic respiratory disease, and healthcare utilization indicators. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated. Results: Across propensity score–matched comparisons, influenza infection was consistently more prevalent among ED patients presenting with acute MI than among most comparator diagnoses. Influenza positivity was significantly higher in MI compared with gastroenteritis (RR 1.97, 95% CI 1.76–2.20), urinary tract infection or urolithiasis (RR 2.29, 95% CI 2.08–2.52), pancreatitis (RR 3.84, 95% CI 2.90–5.08), cholecystitis or cholelithiasis (RR 3.38, 95% CI 2.92–3.91), and appendicitis (RR 5.58, 95% CI 3.62–8.61). Among high-acuity cardiovascular chest-pain presentations, influenza positivity remained higher in MI compared with pulmonary embolism (RR 1.46, 95% CI 1.27–1.68) and aortic dissection (RR 1.85, 95% CI 1.59–2.15). In contrast, no significant difference was observed between MI and myocarditis or pericarditis (RR 0.79, 95% CI 0.51–1.23). Conclusions: In this diagnosis-based, propensity score–matched ED analysis, laboratory-confirmed influenza infection was disproportionately prevalent among patients presenting with acute myocardial infarction compared with a broad range of other acute ED diagnoses. The persistence of this association across infectious, surgical, and high-acuity cardiovascular comparators, alongside the absence of association with myocarditis or pericarditis, suggests that the observed association is not simply due to patients being sicker or undergoing more intensive diagnostic evaluation. These findings are hypothesis-generating and support further investigation into temporal and mechanistic links between influenza infection and acute coronary events.

Background: Artificial intelligence (AI) chatbots are increasingly used by patients and caregivers seeking quick, conversational answers to medical questions. This trend raises concerns about the clinical accuracy and appropriateness of responses, which can influence illness beliefs, treatment expectations, and care-seeking. These concerns are relevant for conditions like asymptomatic bacteriuria (ASB), which is often mistaken for urinary tract infection (UTI), leading to unnecessary antibiotic use. We examined how AI chatbots respond to simulated caregiver questions about ASB/UTIs. Methods. We created two clinical scenarios of hypothetical medical advice questions involving a positive urinalysis without specific UTI symptoms (i.e., ASB) that asked explicitly whether the parent had a UTI (Table 1). Scenario A described only a positive test, whereas scenario B included a fever and malodorous urine. For each scenario, we varied the parents’ gender (mother vs. father) and age (68 vs. 84 years). The eight questions were entered into three publicly available AI chatbots (ChatGPT v5, Gemini v3, and Copilot v5) on December 15, 2025, using private sessions with no memory enabled. Two team members independently coded responses, with discrepancies resolved by two additional reviewers. Results. Most responses endorsed the suggestion of UTI (22/24, 91.7%; Table 2). Responses frequently acknowledged alternative explanations for symptoms (17/24, 70.9%) and over half mentioned ASB (16/24, 66.7%). Antibiotics were mentioned in 8 responses (33.3%), with 6 of those noting potential harms. Most responses recommended seeking immediate care (19/24, 79.2%). Tone varied: 9 (37.5%) stressed urgency (e.g., “this is not something to wait on—he needs urgent medical evaluation.”), 5 (20.8%) were reassuring (e.g., “I hear your concern”), and 10 (41.7%) neutral. Only 7 responses (29.2%) provided citations. Responses varied between scenarios. For instance, antibiotic harms were given for scenario A but not scenario B. Within scenarios (Table 3), responses varied by chatbot (e.g., mentioning ASB [0/4; Gemini] vs. [2/4; ChatGPT] vs. [2/4; Copilot]), parent’s gender (e.g., antibiotics suggested [1/6; father] vs. [3/6; mother]); and age (e.g., alternative diagnoses suggested [4/6; 68 years] vs. [1/6; 84 years]). Conclusions: In response to simulated caregiver medical advice requests about ASB, AI chatbots often endorsed the suggestion of UTI and inconsistently referenced ASB, with variability by platform and patient attributes. These patterns may reinforce misperceptions of ASB and promote antibiotic misuse in older adults. Monitoring and improvement of chatbot outputs, alongside patient-facing guidance on how to use and interpret responses, are needed to support guideline-aligned care.

Background: Healthcare environmental services (EVS) staff play a critical role in infection prevention and control (IPC) through environmental cleaning and disinfection. However, EVS staff are often excluded from structured, role-specific IPC education. Insufficient IPC knowledge among EVS staff may compromise environmental hygiene and increase the risk of healthcare associated infection transmission. This study aimed to assess IPC knowledge and education needs among EVS staff to provide an evidence-based foundation for targeted IPC education programs. Methods A descriptive cross-sectional study was conducted among EVS staff at a tertiary-care university hospital in Seoul, Republic of Korea. Participants completed a self-administered questionnaire assessing demographic characteristics, IPC knowledge, and perceived IPC education comprehension (current level) and education need (required level). IPC knowledge was measured using a 20-item instrument developed based on national IPC guidelines. Education needs were analyzed using the Borich’s needs assessment model and the Locus for Focus model to identify priority education topics. Descriptive statistics and nonparametric analyses were performed. Results A total of 81 EVS staff participated. The median IPC knowledge score was 17.0 (IQR, 16.0-18.0) out of 20. Notably, despite the high overall score, critical knowledge deficits were identified in high-risk IPC areas, including personal protective equipment (PPE) doffing protocols after cleaning an isolation room (42.0% correct) and management of infectious medical waste (17.3%). Education comprehension scores were lowest for management of suspected infection in staff, blood spill disinfection, and the safe use of disinfectants, whereas education need scores were highest for PPE related to various transmission-based precautions, as well as responses to needlestick injuries. Needs assessment using the Borich and Locus for Focus model identified procedures for managing suspected infection in staff (Borich score, 2.47), PPE for airborne precaution (2.00), and PPE for contact precaution (1.94) as the highest-priority IPC education topics, all of which were located in the high importance–high discrepancy (HH) quadrant; needlestick injury management and blood spill disinfection were also identified as high-priority areas. Conclusions Despite relatively high overall IPC knowledge, EVS staff demonstrated significant knowledge–practice gaps in high–risk IPC practices and expressed a substantial need for clearer guidelines essential for self-protection. The discrepancy between current understanding and perceived educational needs underscores the importance of structured, role–specific IPC education. Targeted IPC education programs focusing on isolation precautions, PPE donning and doffing, and occupational exposure management are crucial to enhancing both staff safety and the integrity of hospital-wide infection prevention.

Background: Blood culture contamination leads to increased healthcare costs and patient harm. Routine practice at our institution oftentimes involves placement of a new peripheral intravenous catheter (IV) followed by immediate blood culture collection from the catheter. Published guidelines discourage routine blood culture collection from central venous catheters, but do not address collection from new IV starts. We hypothesized higher contamination rates in cultures collected from new IV starts. To evaluate, mandatory documentation of blood culture collection site was implemented and contamination rates were analyzed. Methods: A prospective observational study was conducted from September to December 2025 at a large quaternary medical center. Peripheral blood culture contamination rates were measured using the CLSI definition. Mandatory documentation of collection site was implemented September 2025 and included an option for “new IV start”. Contamination rates by collection site were compared using chi-squared tests. An estimated cost of $4,538 for each contamination event was based on pooled published cost analyses data. Results: During the study period, 15,926 peripheral blood culture sets were collected and 234 (1.47%) met contamination criteria. Table 1 shows the new IV start contamination rate was significantly higher than all other sites combined (p-value <0.001 with an odds ratio of 1.86 [1.34-2.54]). The difference remained when comparing new IV start to individual anatomic sites. Per year, an estimated 89 contaminations would be avoided if cultures are not obtained from new IV starts with an estimated savings of $403,882 and 267 antimicrobial days. Conclusions: At our institution, it is common practice to collect blood cultures immediately after inserting a peripheral IV. The contamination rate of new IV starts was nearly double the contamination rate of dedicated upper extremity venipuncture leading to increased costs and unnecessary antimicrobial use. The large sample size provides robust data that collecting blood cultures from a new IV start should be avoided and this compelling data should be used to update published guidelines.

Background: We had a large-scale measles exposure event affecting 626 patients. Management of exposed patients was urgent, involving quarantine, post-exposure prophylaxis (PEP), and symptom monitoring on a case-by-case basis. Cases were initially tracked and managed using a combination of multiple spreadsheets amongst stakeholders as well as lists within the electronic health record (EHR). Using shared spreadsheets and lists created significant challenges with maintaining and editing multiple copies and updating workbooks simultaneously. Methods: Infection Prevention and Control (IPAC) worked with primary care personnel and EHR developers to create a shared registry that would prioritize communication and follow-up for exposed patients based on age and immunity. Patients are initially added to the shared registry within the EHR by reviewing non-registry reports and tagging patients, identified using exposure timeframes that overlapped with the index measles cases, in a manner that transferred them to the shared registry. From this registry, measles, mumps, and rubella vaccine status can be confirmed, immune status can be identified, and criteria for PEP assigned. High-risk patients are then contacted with recommendations from IPAC and primary care. Communication and follow-up are tracked directly within the shared registry to ensure appropriate patient management. The exposure management registry is further leveraged throughout the measles outbreak timeframe by allowing real-time monitoring of patients that require additional precautions or guidance related to their exposure. Result: The shared registry enhanced documentation accuracy and transparency between stakeholders. It led to availability of real-time status of exposed patients for the duration of the measles outbreak timeframe. Overall, the registry enabled time-sensitive patient communication to all exposed patients and rapid identification of those who needed PEP. Communication could happen rapidly and seamlessly between care teams within the organization, and the necessary information could be shared quickly with public health authorities as required. Conclusion: Large scale exposures are a challenge to manage and ensure appropriate action and communication occurs. Errors can be prevented by having a single shared exposure management registry. A registry enables care teams to quickly identify and prioritize patients for measles follow-up, communication, PEP, and ongoing management across outbreak timeframes. This process reduces both time and operational burdens of exposure follow-up tracking outside of the EHR.

Background: Central line-associated bloodstream infections (CLABSIs) remain a significant challenge in long-term acute care hospitals (LTACHs), where patients have extended lengths of stay, high device utilization, and complex medical conditions. In 2024, our 11-hospital LTACH system had a CLABSI standardized infection ratio (SIR) of 1.23, performing above (worse than) the national benchmark. A comprehensive, system-wide initiative was needed to reduce preventable infections and improve patient outcomes. Methods: In January 2025, we implemented a multi-modal intervention bundle across 11 LTACHs spanning multiple states. Key components included: (1) A standardized mini-root cause analysis (Mini-RCA) process requiring facility infection preventionists to complete a structured review within 48 hours of each CLABSI event, examining insertion and maintenance bundle compliance, contributing factors, and preventability. Findings were shared with frontline staff and reported to each facility's QAPI committee. (2) Beginning August 2025, corporate infection prevention oversight calls were initiated to review events and identify system-wide patterns. (3) In-house vascular access training was expanded to three facilities, enabling nurses to insert PICCs and midlines under ultrasound guidance, reducing reliance on external contractors and empowering staff to evaluate line necessity and step-down opportunities from central lines to less invasive devices. (4) A blood culture stewardship program was implemented in partnership with pharmacy, emphasizing appropriate culturing indications, transitioning from line draws to two peripheral sticks when feasible, and antibiotic stewardship principles. Results: Comparing full-year 2024 data to January-November 2025, CLABSI events decreased from 56 to 22 (61% reduction). The system SIR improved from 1.23 to 0.53, representing a 57% improvement and performance significantly better than the national benchmark. Central line days decreased by 8% (40,825 to 37,570), and the standardized utilization ratio (SUR) improved from 0.77 to 0.73. Conclusions: Implementation of a multi-modal intervention bundle featuring standardized event review, corporate oversight, enhanced vascular access capabilities, and blood culture stewardship achieved significant and sustained CLABSI reduction across a geographically dispersed LTACH system. The Mini-RCA process created accountability and rapid feedback loops, while in-house line placement empowered clinical staff to critically evaluate device necessity. This approach demonstrates that meaningful infection prevention improvements are achievable in the challenging LTACH setting through systematic, multi-level interventions.

Background: Infection prevention (IP) workflows and staffing continue to be largely designed to provide retrospective surveillance with improvement strategies implemented after infections have occurred despite strong evidence that near real time feedback on clinical care and prevention bundles result in improved clinical care and prevention of infections. While some organizations have implemented centralized surveillance teams to manage chart abstraction for state and national reporting, few have moved toward a prospective surveillance model with their facility-based IP teams. Having implemented a centralized surveillance team in 2015, and an ambulatory specialty IP team in 2017 across a large multi-state healthcare system, a comprehensive IP model redesign was undertaken in 2025 to further transition to a prospective surveillance approach. Methods: Starting January 2025, a prospective surveillance program was launched, combining centralized surveillance, hospital-based generalists, and zone-based specialists in IP. Specialty teams were developed for surgical and procedural services, adult critical care, ambulatory and emergency medicine, and oncology, womens, and pediatric services. Facility-based generalists provide coverage for observation and general medical-surgical units. Staff were assigned roles based on preference and qualifications. About 85% of work hours shifted to direct clinical observation with real-time feedback and coaching of clinical teams. Results: Standardized electronic rounding tools were utilized by both generalist and specialist IPs. Bundle compliance opportunities and trends were displayed on an electronic dashboard and emailed weekly to department leaders. Departments with consistent performance below expectations had to submit action plans to improve performance. In 2025 compared with 2024, total number of IP rounding observations increased 36.8%, CLABSI prevention bundle compliance improved by 8.7% with a 79% increase in the number of lines observed each month, urinary catheter care being completed increased 7.7% with a 52% increase in catheters observed each month, and SSI prevention bundle compliance improved by 8% with a 117% increase in surgical procedure observations. Conclusion Implementing a prospective generalist-specialist model in infection prevention led to significantly more clinical care observations and steady improvements in prevention strategy compliance. Increased visibility and presence on the units resulted in IPs becoming trusted members of the clinical care team. Having a specialist IP role also resulted in improved recruiting of IPs with specific clinical experience and boosting their credibility with the clinical teams. Limitations of this study include the staggered implementation of specialist roles per quarter that may have slowed improvement in specific locations.

Background: Mycobacteria are widely distributed in the environment, and colonization of medical devices using water poses a risk in healthcare settings. Hospital outbreaks linked to ventilators and extracorporeal systems have been reported. At our hospital, dental unit water is routinely cultured every three months. In January 2024, unexpected mycobacterial detection prompted an investigation of dental unit waterlines, tanks, and water sources. Objective: To investigate the presence of mycobacteria in dental unit waterlines and evaluate clinical implications. Methods: Water samples (300ml) from six dental unit waterlines were tested by culture before and after changes in flushing frequency, heater use, and filter replacement. Additional samples from the hospital annex water tanks, main building tank, and nearby parks sharing the same water source were analyzed. Results: Mycobacteria were isolated from all six dental unit waterlines, including M. frederiksbergense, M. chelonae complex, M. mageritense, and M. mucogenicum/phocaicum, with concentrations up to 25 CFU/mL. Increasing flushing from weekly to daily and discontinuing heater use did not eliminate contamination. However, quantitative cultures after filter replacement showed marked reduction, with most lines becoming negative or <0.5 CFU/mL. Mycobacteria were also detected in external water sources: annex water tank (10 CFU/mL), main building tank (<2.5 CFU/mL), and nearby parks (<5 CFU/mL). These findings suggest mycobacteria are not unique to dental units but are ubiquitously present in tap water. Discussion: Detection in both dental units and external water sources indicates widespread colonization rather than isolated contamination. Filtration proved effective in significantly reducing mycobacterial load, emphasizing its role in infection control. Given the pathogenic potential of environmental mycobacteria, especially in immunocompromised patients such as those with neutropenia or hematopoietic cell transplantation, exposure via dental unit water may carry clinical risks. For these patients, use of sterile water instead of tap water during dental treatment is strongly considered. Conclusion: Mycobacteria are present in tap water and dental unit waterlines. Filter replacement effectively reduces contamination. Strict precautions, including sterile water use, are warranted to protect vulnerable patients from opportunistic mycobacterial infections.

Background: Recent research has investigated the role of sinks (including sink taps, filters, water traps, etc.) in the spread of multidrug-resistant organisms (MDROs) and other pathogens. As part of a larger study on hand hygiene (HH) and personal protective equipment (PPE) adherence, we explored healthcare professionals’ (HCP’s) interactions with water and wet surfaces during patient care processes in intensive care units (ICUs). Methods: We conducted ethnographic observations of HCP’s patient care processes in the medical and surgical ICUs of a large academic hospital, and we conducted mini-interviews (~ 3-7 minutes) with a subset of these HCP. Observations focused on HH and PPE adherence during contaminating tasks. We also captured additional relevant data (e.g., room layouts, care activities, fomite/device interactions). We documented observations and interview responses in fieldnotes that we imported into MAXQDA qualitative software and coded activities using a combined deductive-inductive approach. We conducted data collection and analyses iteratively, with early analysis informing later data collection. HCP interactions with water emerged inductively as a topic of interest during this process. Results: Between 3/2022-5/2023, we observed 104 HCP engaged in patient care and conducted 31 mini-interviews. Interactions with sinks and sink-adjacent counters were common. We observed HCP placing pillows and other items on wet counters, water remaining in sinks after use, HCP contacting water droplets on sink walls and counters, and HCP setting items (e.g., IV bags, used towels) in the sink that they later carried to trash or laundry bins. HCP also leaned against surfaces, including sink-adjacent counters and patient-adjacent areas (e.g., beds, bed rails). Such activities could transfer contaminated water droplets to HCP’s clothing, floors, or other surfaces. We also observed water splashing due to sink design or the water pressure when HCP did activities like filling drinking cups or rinsing containers. During mini-interviews, HCP discussed their preference for soap-and-water handwashing (versus hand sanitizer) in specific situations, which they often performed at the same in-room sinks they used during patient care activities as outlined above. Splash back from sink drains could spread pathogens to HCP’s hands. Conclusion: Our study focused on HH and PPE adherence, therefore, we did not systematically collect observations on water in ICUs. Nonetheless, we observed HCP interacting with sinks, water, and wet surfaces in ways that highlight the potential for water-borne pathogen transmission. Infection prevention programs and hospitals should consider these interactions when developing infection prevention guidelines and designing construction and renovation projects.

Background: Guideline-concordant, first-line antibiotic prescribing is a core antimicrobial stewardship strategy to reduce unnecessary broad-spectrum use, antibiotic resistance, and adverse events. Community-acquired pneumonia (CAP) is a common indication for outpatient antibiotics, yet first-line prescribing patterns and equity remain understudied. This analysis assessed associations between first-line prescribing and patient, clinician, and community characteristics in urgent care settings. Methods: Electronic health records from 28 urgent care clinics within an integrated academic healthcare system (January 2023–April 2025) were analyzed. Adults (18+ years) with pneumonia diagnoses and at least one prescribed antibiotic were included. ‘Community-acquired pneumonia’ refers to pneumonia diagnosed in urgent care, though some cases may not meet formal CAP criteria. Episodes were classified by first-line use (CAP without comorbidities: amoxicillin or doxycycline; CAP with comorbidities: either amoxicillin/clavulanate plus doxycycline or a macrolide, or respiratory fluoroquinolone monotherapy). Cluster-adjusted logistic regression assessed differences in first-line prescribing by patient, clinician, and community factors. Results: Among 9,670 episodes (4,966 no comorbidities), first-line prescribing occurred in 90.8% of CAP with no comorbidities and 54.4% of CAP with comorbidities. Mean age was 48.4 years (SD 17.4) for patients without comorbidities and 60.7 years (SD 17.5) for patients with comorbidities; 23% and 48% of episodes occurred among adults ≥65 years. The most common non–first-line antibiotics were amoxicillin-clavulanate and clindamycin, for CAP with and without comorbidities respectively. For CAP without comorbidities, fully adjusted models showed higher odds of first-line prescribing for episodes managed by Advanced Practice Registered Nurses (APRNs) compared to physicians and lower odds among patients with higher neighborhood disadvantage (ADI 26–49 vs 1–25 percentile) as seen in Figure 1. The Area Deprivation Index (ADI) quantifies neighborhood socioeconomic disadvantage (1-100 is least to most disadvantaged). For CAP with comorbidities, Black and Hispanic patients (vs. White) and those treated by APRNs (vs. physicians) had higher odds of receiving first-line antibiotics, while patients in neighborhoods with higher ADI scores had lower odds (vs. 1–25 percentile; Figure 1). Across both groups, no differences were observed by age, gender, or payer. Conclusion: First-line prescribing for outpatient CAP was high among patients without comorbidities but substantially lower among those with comorbidities, with disparities by clinician type, race/ethnicity (comorbidities only), and neighborhood deprivation. These findings reveal systemic inequities in antibiotic stewardship and reinforce the need for equity-focused strategies to support guideline-concordant prescribing. Additional work is warranted to clarify prescribing variation and evaluate relevant modifiers.

Background: Overuse of antibiotics in hospitals leads to resistance to antibiotics, increased consumption of healthcare resources, and adverse drug events. Antibiotic Time-Outs (ATOs) are a recommended antimicrobial stewardship strategy that encourages regular reassessment of antimicrobial therapy that includes indication, spectrum, route, and duration after antibiotic initiation. We evaluated the effect of a hospitalist-led weekly ATO on antibiotic utilization and patient safety outcomes on a high-utilization medical unit. Methods This quality improvement project was conducted on an adult inpatient medical unit with historically high antibiotic use. Baseline antibiotic utilization data were collected from January to March 2025, followed by implementation of weekly hospitalist-led ATO rounds from April-June 2025 with a post-intervention observation phase planned for sustainability assessment. During the ATO rounds, all inpatients receiving systemic antibiotics (excluding those on Infectious Diseases service) were reviewed for indication, microbiology, clinical status, route, and duration. Stewardship recommendations included discontinuation, de-escalation, intravenous-to-oral (IV-to-PO) conversion, and duration optimization. Antibiotic utilization was measured as days of therapy (DOT) per 1,000 patient-days for five targeted agents: ceftriaxone, cefepime, piperacillin-tazobactam, ampicillin-sulbactam, and amoxicillin-clavulanate. Process measures included number and acceptance of stewardship recommendations within 24–48 hours. Clinical outcomes included mortality, length of stay (LOS), and 30-day readmissions for pneumonia, urinary tract infection, cellulitis, sepsis, and diabetic foot infection DRGs. Results Across three months of ATO implementation, 34 patients were reviewed, and 30 stewardship recommendations were issued with 24 recommendations (80%) accepted within 24-48 hours. The most frequent interventions were antibiotic discontinuation, de-escalation of spectrum, and intravenous-to-oral conversion. Compared with the pre-ATO period, the combined DOT for the five targeted antibiotics declined during the ATO phase and was sustained post-intervention, corresponding to an overall ~8% reduction in broad-spectrum IV antibiotic exposure across the study period. Importantly, this reduction was not associated with any signal of harm: mortality, LOS, and 30-day readmission rates for sepsis, pneumonia, UTI, cellulitis, and diabetic foot infections remained stable or improved during both the intervention and post-intervention phases. Conclusion Implementation of a hospitalist-led weekly Antibiotic Time-Out resulted in high acceptance of stewardship recommendations and produced a sustained reduction in broad-spectrum antibiotic exposure without adverse effects on mortality, readmissions, or length of stay. This low-resource, physician-driven intervention represents a scalable and effective approach to improving antimicrobial use and patient safety on high-utilization inpatient units.

Background: After an 18-month period with no Central Line-Associated Bloodstream Infections (CLABSIs), the Critical Care Unit (CCU) at OUMC experienced a cluster of two CLABSIs and one related non-CLABSI event in the first quarter of 2025. This occurred despite established prevention protocols, including daily line necessity rounds, use of MAGIC guidelines for vascular access, universal decolonization, and ongoing staff education, which had successfully lowered infection rates since 2022. All three affected patients were intubated, had an internal jugular (IJ) central venous catheter, and presented with Candida species in their blood and sputum, signaling a potential common etiology. Methods: In response, a multidisciplinary team was convened in April 2025 to conduct a proactive risk assessment using the Failure Modes and Effects Analysis (FMEA) methodology. The FMEA focused on ensuring adherence to the evidence-based policy for central line insertion and maintenance. The team comprised intensivists, interventional radiologists, chief residents, nursing leadership, infection prevention specialists, and a patient safety coordinator to represent all facets of the central line process. Results: The FMEA systematically evaluated potential failures in central line necessity, insertion, maintenance, removal, and environmental cleaning. By calculating Risk Profile Numbers (RPNs), the team identified several high-risk process steps. The highest initial RPN (486) was attributed to the potential for insufficient ultrasound probe cleaning due to improper technique and reliance on visual inspection alone. Other significant failure modes included inconsistent terminal cleaning of patient rooms (RPN 315), potential contamination of IJ lines from patient secretions (RPN 216), lack of role clarity during the insertion procedure (RPN 192), and the use of a single needle for multiple insertion attempts (RPN 189). The cumulative initial RPN for all identified failure modes was 2798. Conclusion: The FMEA proved to be an effective tool for identifying systemic vulnerabilities that contributed to the CLABSI cluster. The analysis led to the implementation of targeted corrective actions, including re-education on and audited monitoring of ultrasound probe cleaning, the introduction of single-use gel packets and individual introducer needles, clarification of the safety observer's role during insertion, and enhanced protocols for protecting IJ dressings. Following these interventions, the total RPN was successfully reduced to 1763. This proactive, systematic approach enabled the team to address specific gaps in practice and reinforce safety protocols to prevent future CLABSI events. No further CLABSIs have been identified since these interventions.