Background: Traditional antimicrobial stewardship (AS) metrics focus on utilization and therapy optimization, but rarely capture the true impact on patient outcomes. Experience from safety initiatives, such as central line-associated bloodstream infections and serious safety events, has shown that metrics quantifying patient harm are essential to drive meaningful change. Related to AS, there is a need for novel measures to quantify antimicrobial-associated adverse drug events (ADE) to inform prescribing behavior. Prior research by infectious diseases (ID) experts found ADEs occurred in 21% of pediatric inpatient antibiotic courses, with risk increasing each day of therapy. Our objective was to assess harm events and identify opportunities for developing antimicrobial-associated harm measures to inform improvement efforts. Methods: We conducted a retrospective chart review to determine the incidence and classify antimicrobial-associated ADEs among hospitalized children. Three non-ID reviewers evaluated a random cohort of patients (<18 years) hospitalized ≤ 60 days between November 2019 and January 2020 who received oral or intravenous antimicrobials for ≥ 24 hours. Sampling was stratified by overall length of stay (LOS) tertiles (1-3, 4, 5+ days). ADEs were defined using clinical criteria from prior literature as occurring within 30 or 90 days of index hospitalization. Reviewers were trained by a nurse informaticist and an ID pharmacist prior to data collection. Weekly case reviews ensured consistency, with ID experts validating 10% of data for interrater reliability. ADEs were categorized by clinical type and antimicrobial class. The frequency of ADEs were compared across LOS category and patient-level total days of antimicrobial therapy (DOT). Result: Of the 411 patients evaluated, (median age: 4 years; 50.9% female) 16.8% (n=69) experienced ≥ 1 ADE. There were 78 total ADEs identified, mostly gastrointestinal (GI) (n=43, 55.1%), dermatologic (n=12, 15.4%), Clostridioides difficile infection (n=8, 10.3%), and vascular device-related events (n=7, 9.0%). GI ADEs were most often associated with fluroquinolones (n=3, 30%), penicillins (n=3, 22.6%), and 3rd generation cephalosporins (n=17, 13.8%). Median DOT was 3 [IQR: 1, 7]; differences in antimicrobial duration between patients with and without ADEs were considered non-significant (p <=/i< 0.2425). ADE incidence increased with LOS tertiles: 1-3 days (n=17, 11.6%), 4 days (n=21, 16.9%), and 5+ days (n=31, 22%). Conclusion: We demonstrated that antimicrobial-associated ADEs are frequent among pediatric inpatients. Developing standardized surveillance systems for antimicrobial ADE detection that are reliably incorporated into AS metrics may be a useful strategy to improve antimicrobial prescribing.

Background RSV vaccine effectiveness (VE) has not been described among nursing home (NH) residents, despite their increased risk for severe disease related to age and chronic heart and lung disease. We assessed bivalent RSVpreF VE in Veterans Affairs (VA) NH residents, overall and stratified by age and comorbidities. Methods We conducted a retrospective cohort study of NH residents over two RSV seasons (October 2023–April 2024; October 2024–April 2025). Inclusion criteria were a confirmed RSVpreF vaccination status (received RSVpreF or no RSV vaccine; other formulations and unconfirmed status excluded) and residing in a NH with RSV testing during the study period. Vaccination status was a three-level time-varying exposure: unvaccinated, vaccinated in current season, or vaccinated in the prior season. Time-at-risk for RSV was limited to continuous stays in VA NH or acute care settings. The primary outcome was laboratory-confirmed RSV infection; severe infections were defined as those requiring transfer to acute care or escalation within acute care. VE was calculated as 1 minus the hazard ratio from Cox models stratified by age and cardiopulmonary disease defined by diagnoses of congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD), adjusted for demographics, calendar year, and conditional on calendar month. Results Among 15,078 unique residents, those aged 60-74 had similar VE when vaccinated in the prior season vs current season, while those aged ≥Figure 1). Similarly, current-season model-adjusted VE was similar for those with and without cardiopulmonary disease. VE for vaccination in the prior season declined modestly among those with cardiopulmonary disease (76% [51–89] to 54% [4–78]). Of 220 total laboratory-confirmed RSV infections, 15 were severe (Table 1). Of the infections, 29 occurred among vaccinated residents of which 1(3%) was severe. Among unvaccinated residents, 14/191 infections (7%) were severe. Residents with severe infections were more likely to be ? Conclusion In this first RSV Vaccine VE study among NH residents, a frail population at high risk for severe RSV disease, bivalent RSVpreF vaccination was associated with a meaningful reduction in laboratory-confirmed RSV infection risk that persisted across two seasons, but with some diminished second-season protection for those with advanced age or cardiopulmonary disease. These subgroups were also overrepresented among those with severe disease and remain an important target for disease prevention.

Background: Healthcare facility-level wastewater surveillance (WWS) is a relatively novel tool for pathogen surveillance. The most sensitive methods for detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in wastewater remain unknown. In this study at skilled nursing facilities (SNFs), two wastewater concentration methods were evaluated for SARS-CoV-2 detection by droplet digital polymerase chain reaction (ddPCR): Electronegative membrane filtration (enMF) and Nanotrap® Magnetic Virus Particles (NP). SARS-CoV-2 case surveillance data from the SNFs was incorporated into this evaluation. Methods: Wastewater samples were collected weekly from manholes at three SNFs over 25 weeks in 2022. Samples were split and concentrated by both enMF and NP, then virus concentration was determined by ddPCR. We utilized a weekly questionnaire and each facility’s National Healthcare Safety Network COVID-19 Report to identify the number of resident and healthcare personnel cases in each facility. Differences in the median SARS-CoV-2 concentration were compared across the enMF and NP methods using the Wilcoxon signed-rank test (?=0.05). Spearman’s correlation (?) was used to evaluate the relationship between the SARS-CoV-2 concentration in wastewater and SARS-CoV-2 case counts. Results: For each facility separately, as well as overall, median virus concentration in wastewater from enMF was higher than that from NP (SNF A: 2.84 vs. 1.49 genome copies [gc]/100 mL; SNF B: 8.50 vs. 6.08 gc/100 mL; SNF C: 5.3 vs. 3.86 gc/100 mL; overall: 5.3 vs. 3.86 gc/100 mL). The Wilcoxon signed-rank test confirmed that the difference in median virus concentrations was statistically significant for SNF B (p=0.001) and overall (p=0.001). Spearman’s correlation results showed overall higher correlations with enMF than with NP and a greater number of statistically significant results among subpopulations. For example: using enMF, the correlation among residents and healthcare personnel combined at SNF A was ?=0.86 (p=<0.0001), at SNF B was ?=0.50 (p=<0.01), and at SNF C was ?=0.59 (p=<0.01), whereas using NP, the correlation at SNF A was ?=0.54 (p=<0.01), SNF B was ?=0.46 (p=0.02), and SNF C was ?=0.23 (p=0.26). Conclusions: enMF yielded higher SARS-CoV-2 concentrations than NP and produced stronger correlations between wastewater signal and case counts, though both methods yielded acceptable results. enMF should be considered as an effective virus concentration method for healthcare facility-level WWS to strengthen and complement clinical methods of case detection.

Background: Ceftriaxone and cefepime resistance among Enterobacterales continues to increase globally, partly due to the rising prevalence of extended-spectrum β-lactamase (ESBL) producing organisms. Surveillance of both resistance patterns and antimicrobial utilization is essential to inform empiric prescribing practices and stewardship strategies. Since carbapenems are frequently used to treat cephalosporin-nonsusceptible Enterobacterales infections, we evaluated trends in ceftriaxone and cefepime susceptibility among Escherichia coli and Klebsiella pneumoniae from 2012–2024 and institutional carbapenem utilization during overlapping years (2019–2025), following outcomes from the MERINO trial for management of ceftriaxone-resistant Enterobacterales infections. Methods: We conducted a retrospective review of annual cumulative inpatient antibiogram data for E. coli and K. pneumonia isolates for 2012-2024. Percent susceptibility to ceftriaxone and cefepime was assessed using Clinical and Laboratory Standards Institute (CLSI) breakpoints among a median of 1,532 E. coli isolates/year and 561 K. pneumoniae isolates/year. (Table 1). Institutional carbapenem utilization (combined meropenem and ertapenem use) was measured as days of therapy (DOT) per 1000 patient-days during 2019–2025 (not specifically representing treatment of E. coli or K. pneumoniae), following implementation of electronic medical record (EMR)–based antimicrobial utilization dashboards. Temporal trends were visualized using line plots. Pearson correlation coefficients (r) were calculated to assess percent susceptibility trends and carbapenem utilization during 2019–2024. Analyses are descriptive; no causal inference was made. Result: During 2012–2024, ceftriaxone susceptibility declined from 89% to 83% among E. coli and from 93% to 82% for K. pneumoniae, while cefepime susceptibility declined from 95% to 88% and 97% to 85% respectively (Figure 1). During the overlapping years 2019–2024, Pearson correlation showed modest downward susceptibility trends for ceftriaxone (E. coli r = −0.900, p = 0.014; K. pneumoniae r = −0.840, p = 0.036) and cefepime (E. coli r = −0.780, p = 0.067; K. pneumoniae r = −0.850, p = 0.033). Institutional carbapenem use increased from 15.2 to 19.3 DOT per 1,000 patient days between 2019 and 2025 (r = 0.79, p = 0.035) (Figure 2). Upon review, carbapenem use was substantially higher in hematology-oncology services (23.7–25.9 DOT/1000 patient-days, during 2022–2025) compared with overall institutional use (15.2–19.3 DOT/1000 patient-days). Conclusion: Ceftriaxone and cefepime susceptibility among Enterobacterales declined over the past decade, coinciding with a modest increase in institutional carbapenem use without a corresponding increase in carbapenem resistance during 2019-2024. Local susceptibility patterns and antimicrobial utilization data provide critical context for stewardship prioritization, especially in high-risk hematology-oncology populations.

Background: Clostridioides difficile infection (CDI) is an important cause of morbidity and mortality worldwide, and in the United States (US) has been declared an “urgent public health threat” by the Centers for Disease Control and Prevention (CDC). The most recently published CDC estimate of the number of CDI infections, hospitalizations, and in-hospital deaths in the US is for 2017. However, CDC’s Emerging Infections Program (EIP) provides ongoing surveillance data; we used EIP annual reports to derive estimates of the number of medically-attended CDI cases, hospitalizations, and deaths in the US in 2017-2022. Methods: Age- and healthcare-associated and community-associated stratified, population-based incidence rates of laboratory-confirmed CDI cases from EIP annual reports were multiplied by age-stratified US Census estimates to derive national estimates of CDI cases in 2017-2022. The percentage of CDI cases hospitalized on the day of or within 6 days of specimen collection, and the in-hospital mortality rates reported in EIP annual reports, were multiplied by the estimated number of CDI cases to calculate hospitalizations and in-hospital deaths for the same years. A similar approach was used to estimate cases, hospitalizations, and in-hospital deaths among persons ≥65 years-of-age. All estimates were compared with published 2017 CDC estimates. Results: We estimated that there were 449,946 laboratory-confirmed CDI cases in 2017, compared to 462,100 cases in the CDC estimate; estimated hospitalizations and in-hospital deaths in 2017 were also similar to the CDC estimate (Figure 1). We estimated 406,130 CDI cases in 2022; 210,079 CDI cases in persons ≥65 years-of-age. We also estimated 170,575 CDI hospitalizations and 9,914 in-hospital deaths in 2022; 88,233 hospitalizations and 5,128 in-hospital deaths in persons ≥65 years-of-age. From 2017-2020, the estimated number of CDI cases, hospitalizations, and in-hospital deaths declined by 22%, 33%, and 58%, respectively, and from 2020-2022 estimates increased by 16%, 8%, and 8%, respectively. Among persons ≥65 years-of-age, estimated CDI cases declined by 14% from 2017-2020, and increased by 6% from 2020-2022; from 2017-2020, estimated hospitalizations and in-hospital deaths declined by 34% and 67%, respectively, and remained stable from 2020-2022 (Figure 2). Conclusion: CDI burden estimates from EIP annual reports were comparable to CDC estimates, supporting the use of EIP data to derive national estimates. The US CDI disease burden is high and has increased since the COVID-19 pandemic. Interventions are needed to reduce the US CDI disease burden, particularly in older age groups.

Background: Clostridioides difficile infection (CDI) is a common healthcare-associated infection. Despite its well-characterized nature, literature remains divided on the impact of obesity on CDI. Through the Emerging Infections Program’s CDI surveillance, we investigated the influence of obesity — with and without comorbidities, on CDI compared to non-obese patients residing in Davidson County, Tennessee. Methods: Fully abstracted CDI cases, defined as the first positive stool test for persons at least 1 year old, residing in Davidson County, Tennessee from 2016–2023, were examined. Study groups included BMI ≥ 30 with no comorbidities (BMI30), BMI ≥ 30 with at least 1 comorbidity (BMI30C), and BMI < 30 (BMI<30). Pairwise comparisons of characteristics and outcomes were made via logistic regression custom hypothesis tests for categorical variables and Tukey-Kramer test for continuous variables. All outcomes were adjusted for age; stepwise logistic regression determined significantly associated patient characteristics for further adjustments. Statistics were conducted using SAS 9.4. Results: There were 623 patients identified (BMI30: n=45, BMI30C: n=136, BMI<30: n=442). BMI30 had the highest proportion of female patients (BMI30: 77.8%, BMI30C: 61.0%, BMI<30: 59.5%) and were the youngest group (BMI30: 47.0 years, BMI30C: 57.8 years, BMI<30: 59.0 years). BMI30C were more likely to be Black than BMI<30 (BMI30C: 36.0%, BMI<30: 16.7%). BMI30C were more likely than BMI<30 to be diagnosed with diabetes, chronic kidney disease, neuropathy, or a chronic ulcer/wound of the skin. BMI30 were the most likely to be community-onset (adjusted: BMI30: 78.9%, BMI30C: 59.4%, BMI<30: 66.8%) and least likely to be community-onset healthcare facility associated (adjusted: BMI30: 15.5%, BMI30C: 34.4%, BMI<30: 27.7%). BMI30C were more likely to have diarrhea (≥3 unformed stools in one day) than BMI<30 (BMI30C: 64.9%, BMI<30: 51.2). BMI30 were least likely to be admitted (adjusted: BMI30: 44.0%, BMI30C: 71.8%, BMI<30: 68.1%). Among admitted patients, there were no significant differences in ICU admissions or length of stay. There were no significant differences in 90-day mortality, number of cases, proton pump inhibitor, H2 blocker, or antibiotic use in any groups. Detailed statistics are available in tables 1–3. Conclusion: Variances in symptoms, case classification, and admissions, paired with similarities in mortality and length of stay between groups, demonstrate that providers should consider a patient’s unique health history when managing CDI, rather than adopting a uniform approach for all obese patients. Future studies with more diverse patient populations could guide clinicians in bettering the treatment and prevention of CDI in at-risk populations.

Background: Rates of Candida auris are rising across the US, particularly in New York. Due to C. auris’ affinity for environmental contamination and prolonged skin colonization, rapid implementation of comprehensive infection prevention & control (IP&C) measures is essential. Given the complexity and multidisciplinary involvement required for these efforts, we developed the C.A.R.E (Candida Auris Response & Engagement) framework in response to an inpatient outbreak to guide multidisciplinary efforts and provide a model for other facilities facing similar challenges with C. auris or other pathogens with extensive contact transmission. Methods: A C. auris cluster was identified in an 862-bed New York City academic medical center between July and October 2025. 23 cases were found involving a medical stepdown unit and adjacent intensive care unit. Baseline IP&C C. auris efforts include isolation precautions (gown and gloves), twice-daily room cleaning/disinfection, dedicated equipment, ATP testing of high touch surfaces (HTS) post terminal room cleaning, observations of personal protective equipment (PPE) use and hand hygiene, and screening of exposed roommates. After an August point prevalence surveillance (PPS) identified additional cases, we expanded interventions across various categories. The C.A.R.E. framework (Fig. 1) summarizes baseline and expanded efforts during this cluster. Figure 1. The C.A.R.E. (Candida Auris Response & Engagement) Framework to approaching a rise in C. auris cases. Results: Of 23 cases, 83% (19/23) were detected through surveillance. Clinical cases included bloodstream (3/4) and respiratory (1/4) sources. Shared rooms, either roommates or subsequent room occupants, were associated with 52% (12/23) of cases. Following implementation of the C.A.R.E. framework, further transmission ceased, confirmed by two negative rounds of PPS on each unit (Fig. 2). Figure 2. A timeline of C.auris cases identified on 2 units with corresponding IP&C effort implementation. To address identified gaps, a C. auris task force was created to improve IP&C processes. Key actions included clarifying equipment cleaning responsibility in collaboration with Environmental Services and Nursing, reevaluating the C. auris isolation category, and expanding screening for high-risk patients. Further, we incorporated fluorescent marker audits alongside ATP testing into routine practices to monitor environmental and equipment cleaning. While not all measures in the C.A.R.E. framework may be needed for every outbreak, facilities can adapt and scale interventions based on feasibility and outbreak severity. Conclusions: Effective prevention of C. auris transmission requires coordinated and multidisciplinary efforts. Establishing a structured response after early case detection can help close gaps in infection prevention that contribute to spread.

Background: vSNFs are known reservoirs of MDROs. However, data are lacking on how MDRO carriage may differ between residents in ventilator-capable (vBed) and non-ventilator-capable (non-vBed) areas within vSNFs. Methods: We conducted two point-prevalence MDRO sweeps in two vSNFs (Facility A: 44 vBeds/55 non-vBeds; Facility B: 31 vBeds/167 non-vBeds) from May-June 2025. All occupied beds were sampled except for Facility B’s non-vBeds which randomly sampled 50 beds due to size. Sampling involved hands, axilla/groin and peri-rectal areas cultured for MRSA, ESBL, VRE, C. auris, CRAB, and CRE, plus bilateral nares swabs cultured for MRSA and C. auris. Descriptive statistics summarized overall and MDRO-specific prevalence across body sites, with differences between vBed and non-vBed residents evaluated using t-tests and chi-square tests. Results: Overall MDRO prevalence was higher in vBeds (83.9%, 115/137) than non-vBeds (73.2%, 145/198; p=0.029) although the rank order of carriage was similar: MRSA > ESBL > VRE > C. auris > CRAB > CRE. vBed residents had significantly higher prevalence for all pathogens except MRSA (Figure). Multi-MDRO burden was greater in vBeds (mean 2.3 MDROs/resident) than non-vBeds (1.3; p<0.001); vBeds had a substantially higher likelihood of carrying ≥3 (46.0% vs 13.6%; p<0.001), ≥4 (24.1% vs 4.0%; p<0.001), or ≥5 MDROs (10.9% vs 1.0%; p<0.001). Emerging MDROs (CRE, CRAB, C. auris) were more prevalent in vBeds (43.1% vs. 19.7%; p<0.001), and were highly associated with endemic MDRO co-carriage (98.3% [58/59] vBeds; 97.4% [38/39] non?vBeds). The mean number of positive body sites was higher in vBeds (2.4 vs 2.0; p=0.003), with a higher likelihood of being positive at ≥2 sites (73.0% vs 59.6%; p=0.009), ≥3 sites (51.1% vs 39.4%; p=0.017), or 4 sites (35.0% vs 23.7%; p=0.010). vBed residents were more likely to have axilla/groin carriage (79.6% vs 58.1%; p<0.001) with non-significantly higher carriage at other sites (Figure). Nasal carriage patterns differed by organism: MRSA prevalence was similar between vBed and non?vBed residents (29.2% vs 32.8%; p=0.559), whereas C. auris was markedly higher in vBeds (29.2% vs 4.0%; p<0.001). Conclusion: Carriage of both endemic and emerging MDROs is widespread in vSNFs, affecting ~75% of residents regardless of ventilator status. However, vBed occupants were more likely to harbor an MDRO, and more likely to harbor multiple MDROs at multiple body sites. Emerging pathogens were also more common in vBed occupants, and were almost always associated with co-carriage of endemic MDROs. Guidance is needed for comprehensive MDRO response in vSNFs.

Background Ethiopia’s Ministry of Health (MoH), in collaboration with ICAP at Columbia University and the U.S. Centers for Disease Control and Prevention, sought to establish five infection prevention and control (IPC) Centers of Excellence (CoEs) with the ultimate goal of promoting effective and sustained implementation of IPC interventions. The CoEs are based on MoH IPC CoE guidance and leverage capacity gained through previous initiatives including implementation of a national IPC Advanced Training Program and a national monitoring and evaluation system. CoEs are encouraged to develop innovative solutions to challenges and serve as a reference for other healthcare facilities. We describe the initial phase of establishing IPC CoEs. Methods In 2023, five hospitals were selected based on the following criteria: experience implementing IPC interventions, hospital size and location, supportive leadership, and willingness to disseminate findings. Selected hospitals used the WHO multimodal improvement strategy to strengthen IPC over nine months, starting with environmental cleaning programs in maternity units. Facility-level baseline assessments and unit-level environmental cleaning needs assessments were created and conducted, followed by the development of operational plans to address identified gaps. The implementation team provided training, mentorship, and resources (e.g., CDC’s Best Practices for Environmental Cleaning in Healthcare Facilities) to each facility. Initial and follow-up audits assessing visual cleanliness and availability of appropriate cleaning materials were conducted after <3 months to assess progress. Results Baseline assessment demonstrated that all hospitals outsourced environmental cleaning services. None of the hospitals provided regular training upon employment or had job-aids for environmental cleaning staff. One hospital had an environmental cleaning policy. The maternity unit needs assessment identified gaps in IPC standard operating procedures (SOPs) at four hospitals. During implementation, all facilities developed operational plans to guide improvements, subsequently creating or updating environmental cleaning policies and SOPs. Hospitals worked with environmental cleaning companies to train cleaning staff and monitor cleaning. Mean audit scores across four hospitals increased from 51% at baseline (range 22-90%) to 83% (range 71-94%); a follow-up audit was not conducted at one hospital. Conclusion Initial efforts to establish IPC CoEs demonstrated that hospitals with existing IPC capacity built from national programs successfully led interventions to address identified gaps in environmental cleaning programs. Further work is needed to determine whether the interventions are sustainable long-term and whether interventions can be applied to other wards and healthcare facilities in the country.

Background: Midlines and peripherally-inserted central catheters (PICC) have increased in use due to their ease of insertion, low insertion risk to patients, and relatively low cost. Three common complications are central line-associated bloodstream infection (CLABSI), upper extremity deep venous thrombosis (DVT), and lumen occlusion. The literature reports PICC-associated CLABSI rates of 0.5-2.1 per 1000 catheter days, DVT rates of 1.4 to 9.5%, and lumen occlusion 5 to 16.1%. Both CLABSI and lumen occlusion are more common in multi-lumen than in single lumen (SL) PICC. Our objective is to evaluate the appropriateness of midline and PICC lumen selection, to assess for rates of complication, and to identify targets for clinical decision support intervention. Methods: Setting. This is a retrospective cohort study of adult patients ≥18 y.o. with a midline or PICC placed by the Vascular Access Team (VAT) between 1/1/24 and 6/30/25 at a 500-bed academic safety net and teaching hospital. Data abstraction. Indication for line placement was determined by VAT consultation order or manual chart review. Upper extremity DVT was screened by ICD10 codes and confirmed through manual chart review. CLABSI was determined through cross-reference to National Healthcare Safety Network data. Alteplase administration was used as a surrogate for lumen occlusion. Appropriateness criteria. Appropriateness of midline and PICC lumen selection was determined by adapting the Michigan Appropriateness Guide for Intravenous Catheters and Michigan Multi-Lumen Appropriateness Criteria (Figure 1). Results: Six hundred twelve midline (n=97, all SL) or PICCs (n=515) were placed into 524 patients in the study period (SL PICC, n=213; double lumen [DL] PICC, n=243; triple lumen [TL] PICC, n=59). The indication for line differed based on the line type (Table 1). The majority of midlines (95.9%) and SL PICCs (99.5%) were deemed appropriate; in contrast, 74.1% of DL PICC and 3.4% of TL PICC were considered appropriate. Complications of midline and PICC were rare (CLABSI: 0.19 per 1000 line days; DVT: 1.1%; lumen occlusion: 11.8%). Any complication occurred in 12.9% of cases and was more common in multi-lumen as compared to SL devices (i.e. midline or SL PICC) (19.9% vs 6.1%, P). Conclusion: Opportunities exist to reduce multi-lumen PICC insertion. This may decrease device-related complications. Optimizing lumen selection through clinical decision support may improve patient safety and vascular access outcomes.

Background: The National Healthcare Safety Network Antimicrobial Resistance Option (NHSN AR) is the nation’s primary tracking system for antimicrobial resistance. As of December 2025, 89% of Washington (WA) acute care hospitals are reporting antimicrobial susceptibility data to the AR option. The AR option provides a feature to generate antibiograms, a clinical tool to guide empiric antibiotic selection. However, the NHSN generated antibiograms do not adhere to the Clinical and Laboratory Standards Institute’s widely used M39 (CLSI M39) guidelines, which are best practices for antibiogram creation. Due to concerns of limited clinical applicability, we sought to create a CLSIM39 compliant antibiogram dashboard using NHSN AR data to support hospitals to make informed clinical decisions and track local resistance data. Methods: We downloaded the line list for All Antimicrobial Resistance Events from NHSN, transformed the data in R, and imported it into PowerBI to generate interactive antibiogram reports. The initial dashboard focused on the most commonly reported Gram-negative pathogens in WA: Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa. We included isolates from blood, cerebrospinal fluid, lower respiratory tract, skin and soft tissue, wound, musculoskeletal, and urine specimens. Following CLSI M39 guidelines, we retained only the first isolate per organism per patient per calendar year. For specimen-specific reporting, we applied specimen filters by source prior to isolate selection. We selected antimicrobials and final susceptibility interpretations to calculate percent susceptible based on CLSIM39 and M100 guidelines. We suppressed organism-agent combinations with fewer than 30 isolates tested or lack of clinical relevance. To improve interpretability, we included the median and range of isolates tested for each organism. Three antibiograms were available: all-specimen sources, blood only, and urine only. To ensure data security, we assigned hospital alias codes and hosted the dashboard on a secure PowerBI platform. Results: WA DOH launched the NHSN AR Antibiogram Dashboard in December 2025. The dashboard displays susceptibility data based on analysis of 209,836 isolates collected between 1/1/2020 and 11/30/2025. We generated 74 all-specimen, 43 blood, and 74 urine-specific facility antibiograms. Currently, 93 antimicrobial stewards representing 80 hospitals have dashboard access, enabling them to track antimicrobial resistance trends year-to-year and compare resistance patterns by specimen source. Conclusion: The dashboard equips antimicrobial stewards with actionable data to monitor local resistance trends and inform facility-specific antimicrobial use guidelines. We plan to expand the dashboard to include additional organisms and specimen-specific reports.

Background: Cook Children's has two hospitals in North Texas and a network of clinics extending to the West, where a measles outbreak totalling 762 cases began on January 20, 2025. Measles symptoms include fever, cough, coryza, and conjunctivitis before the onset of the morbilliform rash. Timely isolation is recommended for measles. Isolation should continue from four days before to four days after the onset of rash. We hypothesized that contact, travel, and symptom-based screening could prevent amplification of measles in our healthcare settings and avoid positive screens in most neonates with febrile URI. Administratively, screening is unpopular because screening leads to longer registration times, more manpower requirements, and lower patient satisfaction scores. Methods: We selected five measles screening questions employing an adjustable scoring system in which a total score of 5 triggered a positive registration screen, rapid isolation, and further clinician assessment to determine actual testing needs. We scored practice patients by trial and error to settle upon a scheme, then deployed screening at all registration points. We adjusted questions based on evolving local measles epidemiology and redeployed the questions. We monitored throughput. Results: Screening for the first iteration started network-wide on March 31, 2025 (Table 1). Scoring included: 1 point for travel to/living in a measles area; 2 points for case exposure; 1 point for no measles vaccination; 2 points for fever; 1 point for ALL 3 C's – cough, congestion, and red eyes. Not anticipating that parents would answer "UNKNOWN" to some questions, a point counted for those instances. Initially, screen positivity was 0.32% (256 of 80,071), while there were 0 PCR-positive cases. The second iteration (55,603 screens) mended the oversight, reducing positive screens to 0.01%. During a third iteration (70,018 screens) following a visitation to a resort by an outbreak-linked case, "ANY," rather than "ALL of the 3 Cs," and/or rash was counted, increasing screen positivity to 0.03%. After a worrisome non-network case presented without travel or known exposure, a fourth iteration (215,957 screens) increased the maximum to 2 points for each 3C or rash (1/2 point for each), so children without travel or known exposure could have a positive screen. Positivity was 0.01%. For iterations 2-4 (341,578 screens), using measles PCR (n=27) positive as the gold standard, sensitivity was 100%, specificity 96%, PPV 50%, & NPV 100% (Table 2). Using "clinician felt PCR was needed" as a gold standard, clinicians ordered PCR in only 5.7% of positive screens and 0.01% of negative screens, including 3 children with fever and vaccine-associated rash only (Table 4). Registration throughput climbed by 117% but returned to baseline by 2 months (Graph). However, managers were pressed into service directing traffic until screening ended July 27, 2025. Conclusion: Exposure and symptom-based measles screening can avoid positive screens among low-risk febrile neonates with URI. This model should be employed in other areas to prevent measles transmission before the onset of rash.

This article introduces CriTaRep v1, a geo-coded event dataset documenting state repression against Crimean Tatars (2000–2024). Drawing on locally sourced materials in Crimean Tatar, Ukrainian, and Russian languages, CriTaRep records n = 709 repression events affecting more than 2,200 individual victims. We inductively identify 22 repression types across three categories: deprivation of liberty, legal and administrative repression, and physical repression. Russia’s 2014 annexation of Crimea marked the onset of a large-scale and systematic repression campaign against the Crimean Tatar population. We document a concentration of arbitrary searches on Thursdays, physical repression targeting elites, and intensified repression during periods of dissent. Empirical analyses show that repression spikes in response to protest activity. Russian authorities respond rapidly and increasingly harshly to dissent, pursuing a dual strategy of protest suppression and long-term deterrence. CriTaRep fills critical gaps in existing datasets and provides new opportunities to study patterns and mechanisms of demographically targeted repression in Russian-occupied territories and beyond.

Background: Prospective audit and feedback (PAF), a cornerstone of antimicrobial stewardship programs (ASP), relies on infectious disease (ID) clinicians’ direct review of electronic health records (EHR). We assessed the consistency of ID clinicians’ EHR-based assessments on real-world patient data. Methods: Antibiotic orders were randomly selected from a list of hospitalized adults at UCSF medical center. ID specialists (physicians and pharmacists) independently reviewed orders in real time using data from the EHR. Reviewers assessed the stated need for antibiotics, their agreement with necessity and choice, and overall appropriateness as defined by the National Antimicrobial Prescribing Survey (NAPS) tool. We measured agreement with either Cohen’s kappa or weighted Cohen’s kappa for ordinal observations. Results: Conclusion: We observed only modest agreement between independent ID clinicians’ reviews of antibiotic orders in a real-world assessment of inter-rater agreement. Discrepancies in assessments likely reflect a mixture of practice pattern variation, the intrinsic difficulty of assessing antibiotic choice without directly evaluating the patient, and variation due to the instruments used to collect information. Reference: Khanina A, Douglas AP, Yeoh DK, et al. Validation of the Antifungal National Antimicrobial Prescribing Survey (AF-NAPS) quality assessment tool. J Antimicrob Chemother. 2023;78(6):1367-1377. doi:10.1093/jac/dkad085

Background: The rapid clinical translation of human gene therapy products, particularly those utilizing replication-deficient viral vectors such as adenovirus and adeno-associated virus, has introduced novel biosafety considerations regarding "shedding"—the dissemination of the vector through patient urine, saliva or stool. While therapeutic protocols focus on patient outcomes, unintentional exposure of healthcare workers, caregivers, or other close contacts to these viral vectors represents a critical, yet under-analyzed, epidemiological event. Objective: To critically evaluate the hazards posed by accidental exposure to recombinant viral vectors from an epidemiological perspective, focusing on risks of horizontal transmission and immunological interference. Discussion: Although modern viral vectors are engineered for safety, unintentional exposure via mucosal contact or accidental inoculation poses multiple risks that warrant critical evaluation. First, immunological priming or seroconversion in an exposed individual can induce development of neutralizing antibodies against the specific vector capsid. Such "silent" immunization may preclude an individual from receiving future gene therapies, creating a long-term public health barrier. Second, while rare, the risk of in vivo recombination with wild-type viruses (e.g., a natural adenovirus infection) could theoretically result in the rescue of replication-competent viral variants. Third, the biodistribution and persistence of a transgene in non-target populations remains poorly characterized. Identifying and tracking these events is essential for refining risk to public health, the environment and development of adequate containment guidelines for human gene therapy treatments utilizing viral vectors. Conclusion: Unintentional exposure to recombinant viral vectors represents a significant, under-recognized epidemiological hazard. To ensure the safe expansion of genetic medicine, it is imperative to move beyond patient-centric monitoring and treat unintentional exposures as epidemiological data points. Systematic surveillance of these events is vital for establishing a real-world safety profile of genetic medicines, refining biosafety protocols and safeguarding public health.

Background: Portable medical equipment is a potential source for transmission of healthcare-associated pathogens. However, cleaning and disinfection of equipment is suboptimal in most healthcare facilities. Methods: On a long-term care facility (LTCF) ward, we examined the impact of an intervention in which a far ultraviolet-C wand was used to provide low-level disinfection of portable equipment and high-touch items in common areas. The surrogate markers bacteriophage MS2 and cauliflower mosaic virus DNA were inoculated onto 5 portable medical devices in the morning on day 1; in the afternoon on days 1, 3, and 7 swabs for recovery of the markers and culture for pathogens were obtained from 50 surfaces including portable equipment, common areas, and resident rooms. The percentages of sites with contamination were compared for the week of the intervention versus for a control week without far UV-C exposure. Results: In the control period, the DNA marker and bacteriophage MS2 disseminated widely and were detected on non-inoculated equipment, the nursing station, and in resident rooms. In comparison to the control period, there was a significant reduction in contamination with the DNA marker during the far UV-C intervention period (P<0.01), and a trend toward reduced contamination with bacteriophage MS2 (P=0.20) and pathogens (P=0.11) (Figure). Conclusions: Surrogate markers inoculated onto portable medical equipment disseminated widely throughout a LTCF ward. Daily low-level disinfection using a far UV-C wand reduced dissemination of the surrogate markers and there was a non-significant reduction in pathogen contamination.

Background: Urine testing is common among hospitalized patients with indwelling urinary catheters, yet variation in collection practices may compromise diagnostic accuracy and contribute to unnecessary downstream interventions. Guidelines recommend avoiding sampling from indwelling catheters when feasible to reduce contamination and detection of asymptomatic colonization. However, real-world compliance and its relationship to diagnostic urine test results, subsequent UTI diagnosis, and antimicrobial prescribing remain incompletely characterized. Methods: We conducted a retrospective medical record review of adult patients who underwent urine testing between March and November 2024 and had an indwelling urinary catheter or catheter removal within the prior 24 hours. Urine samples were classified as compliant if obtained after catheter removal and noncompliant if collected with a catheter in place. Analyses included all urine samples, with urinalysis-specific analyses limited to samples with available results. Urine collection practices, urinalysis parameters, urine culture outcomes, provider-documented UTI diagnoses, concordance with symptom-based criteria and IDSA/NHSN definitions, and antimicrobial prescribing following urine testing (receipt, timing, route, and duration) were summarized descriptively and stratified by compliance status. Results: A total of 921 urine samples were included; 663 had an initial urinalysis with reflex urine culture, while the remainder underwent urine culture alone. Samples compliant with recommended collection practices accounted for 59% of cases. Among samples with urinalysis, overall positivity was similar in compliant and noncompliant samples (57% vs 55%), with comparable urinalysis component positivity across compliance groups. Urine culture positivity was also similar across compliance groups in both reflex-culture and culture-only samples (29% vs 27% and 27% vs 29%). Gram-negative organisms predominated (13-15%), followed by fungi (7-12%) and Gram-positive organisms (2-4%), with fungal isolates more common among noncompliant samples. Antimicrobial therapy was prescribed in 19% of compliant samples compared with 15% of noncompliant samples and was frequently initiated before culture results in both groups. Median treatment duration was similar (7 vs 6 days). Provider-documented UTI diagnoses were common (80% vs 84%); however, only a portion met standardized UTI definitions (IDSA criteria: 41% compliant vs 32% noncompliant), with greater concordance observed among compliant samples. Conclusion: Recommended urine collection practices were followed in just over half of samples, with similar urine test positivity across compliance groups. Differences in organism distribution, antimicrobial prescribing, and concordance between provider-documented and standardized UTI diagnoses suggest that urine collection practices may influence diagnostic classification and antimicrobial decision-making in hospitalized adults.

Background: Pyogenic arthritis is a commonly encountered condition by Infectious Diseases clinicians and can occur in native joints as well as prosthetic joints. Synovial fluid culture is key in identifying the pathogen but there is a high incidence of culture-negative infections – up to 40% in native pyogenic arthritis and up to 15% in prosthetic joint infections. Multiplex polymerase chain reaction (PCR) testing offers the potential for rapid organism identification but real-world data on utilization of the test is lacking. Methods: A health system in the Chicagoland area recently began use of the BIOFIRE® Joint Infection Panel, which tests for 39 common bacterial and fungal causes of joint infection, as well as several markers of antimicrobial resistance. If the PCR is ordered, a synovial fluid culture must also be ordered. Of note, coagulase-negative staphylococci and Cutibacterium acnes are not targets on the PCR panel. A retrospective review was conducted of synovial fluid PCR testing among 5 hospitals from 1/1/25 – 12/6/25. Result: A total of 168 synovial fluid PCR tests were sent and 48 (28.4%) were positive. Age, gender, and race/ethnicity were similar between the PCR-positive and PCR-negative groups. In the PCR-positive and PCR-negative groups, 54.2% and 57.5% of patients had a prosthetic joint, respectively. All patients also had a synovial fluid culture obtained. Among patients with a positive PCR test, PCR and culture results were concordant for 31 (64.6%) patients. Of the 17 patients with a positive PCR but a discordant culture result, 14 had a negative synovial fluid culture and 3 had a culture identifying the organism found on PCR but also a second bacteria (Staphylococcus epidermidis, C. acnes, Finegoldia magna). Additionally, 90.8% of negative PCR tests had a corresponding negative culture result. Among the 12 patients with a negative PCR and a positive culture, six (50%) had growth of organisms included on the PCR panel (Staphylococcus aureus [n=2], Pseudomonas aeruginosa [n=2], Escherichia coli [n=1], Streptococcus infantarius [n=1]). The remaining isolates (Pasteurella multocida, Corynebacterium striatum, S. epidermidis [n=2], Dermabacter hominis, and Haemophilus parainfluenzae) were off-panel organisms. Conclusion: Synovial fluid PCR paired with culture can decrease the incidence of pyogenic arthritis without an identifiable pathogen among patients with native and prosthetic joint infections. Further research should examine the impact of the PCR test on antibiotic use, including time to targeted therapy, which may inform diagnostic stewardship recommendations regarding the test.