Background: Community-acquired pneumonia (CAP) is most commonly caused by Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis or atypical bacteria. Legionella pneumonia is most commonly associated with contaminated man-made water systems. The 2019 CAP guidelines endorsed by the American Thoracic Society and Infectious Diseases Society of America are the only national guidelines that recommend the Streptococcus pneumoniae urinary antigen test (UAT) in patients presenting with severe CAP, and the Legionella UAT in patients presenting with either severe CAP or with recent travel to an area associated with a Legionella outbreak. Since the publication of this guideline, several publications have questioned the utility of these UATs in clinical practice. Methods: We conducted a retrospective review of Streptococcus pneumoniae and Legionella UATs ordered for inpatient adult patients at the University of Kentucky Healthcare during the calendar year 2024. Chart review was conducted for all patients with a positive UAT to determine indication and appropriateness of test ordering, and details of antimicrobial prescription and duration. Results: Of the 6,421 orders, only 168 (2.8%) were positive – 153 Streptococcus pneumoniae UAT and 15 Legionella UAT. Patients with a positive test were reviewed to determine diagnostic indication for the test as well as to evaluate antibiotic de-escalation practices. Of the positive UATs, 37.5% of the orders were obtained in patients who did not have CAP. Most common indications were VAP, HAP, aspiration pneumonia, acute respiratory failure, sepsis, COPD exacerbations, and CHF exacerbations. None of the patients with a positive Streptococcus pneumoniae UAT were narrowed to amoxicillin to target the pathogen. Most commonly, patients were narrowed from cefepime to ceftriaxone or atypical coverage was discontinued. For patients with Legionella pneumonia, macrolide therapy was extended beyond the typical three-day regimen used in CAP or changed to a respiratory fluoroquinolone. Conclusion: Based on our review, we are recommending removing the Streptococcus pneumoniae UAT from our institution’s formulary and optimizing the Legionella UAT order by limiting use to patients with risk factors. This proposal will result in significant cost savings as our enterprise spent $164,211 on UATs that did not significantly influence care for most patients.

Background: Central-line associated bloodstream infections (CLABSI) are defined as bacteremia, or fungemia, in patients with a central intravascular device and no other apparent source of infection. In cases where devices are not removed, treatment of CLABSI involves eradication of intraluminal infection with systemic antibiotics and supratherapeutic concentrations of antibiotics inside the catheter, creating an antibiotic lock. Antibiotic locks can also be used in selected high-risk individuals and those with recurrent CLABSI for prevention. In this review, we evaluated the use of antibiotic locks for the treatment and prevention of CLABSI at South Texas Veterans Health Care System (STVHCS) to assess if use has been in accordance with standard of care. Methods Retrospective data review of STVHCS electronic medical records from 2020-2025. Data collected is limited to age, catheter type, purpose of antibiotic lock (treatment or prevention), organism targeted, antibiotic used for lock, duration, use of systemic antibiotics, and if the intervention was successful at 30 and 90 days. Appropriate lock used was defined as in accordance with the IDSA 2009 CLABSI treatment guidelines, or the 2022 SHEA compendium. Results Data available demonstrated that over the past 5 years there have been 18 instances of antibiotic lock use in 16 patients. Of this population, 13 of 18 lines involved were tunneled hemodialysis catheters with the remaining being ports (3), and tunneled central lines (2). Six of these instances were used for prevention of CLABSI due to long-term hemodialysis catheters/recurrent CLABSI, while the remaining 12 were used as treatment. Per IDSA CLABSI guidelines, removal of a catheter was recommended for 8 of 18 cases, (Staphylococcus aureus, Enterococcus spp., and metastatic infection). Of those cases, 6 patients had removal of catheter, whereas the remaining 2 patients had catheter salvage. The retention of the catheters were in accordance with IDSA guidelines as they received systemic antibiotics with concomitant lock therapy and had no alternative venous access and removal was contraindicated. We found at 30 days, all patients had survived. Whereas at 90 days, 4 patients had expired due to other all-cause mortality and unrelated to recent CLABSI infection. Conclusions Based on this retrospective review, there were 18 instances of antibiotic lock therapy that appeared to be in accordance with clinical guidelines for both prevention and treatment of CLABSI. This data review is part of the antibiotic stewardship program and will be used to develop future quality improvement processes.

Background:?Residents of long-term care facilities (LTCFs) are particularly vulnerable to infection and colonization with multidrug-resistant organisms (MDROs) due to immunologic vulnerability and prolonged healthcare exposure. Interfacility transfers (IFT) of these residents between LTCFs and acute care hospitals are common. Understanding trends in MDRO admission prevalence among LTCF transfers is important for hospitals considering targeted screening and implementation of protocols to prevent transmission. While the COVID-19 pandemic stalled national progress in MDRO prevention, it is unclear how MDRO admission prevalence trends among LTCFs transfers shifted. We aimed to (1) identify longitudinal trends in MDRO admission prevalence and (2) analyze shifts in these trends relative to the pandemic onset. Methods:?Hospital discharge data from the Healthcare Cost and Utilization Project Arizona State Inpatient Databases were evaluated from Oct 2015–Dec 2023. Acute care admissions for patients over 18 years old with LTCF identified as the admission source were included in the study; 12 epidemiologically important MDROs were identified via ICD-10 codes for each admission. The annual frequency and proportion of patients transferred to hospitals from LTCFs with evidence of MDRO prevalence at admission were described. Longitudinal trends in MDRO admission prevalence among all LTCF-hospital transfers were evaluated using the Cochran-Armitage trend test. Multivariable logistic regression was used to model the odds of MDRO admission prevalence – defined as documented colonization, history, or infection POA – by year, adjusting for age, sex, race, ethnicity, and rurality of patient residence. Results:?Among 14,195 Arizona IFTs from LTCFs to acute care hospitals during the 8.25-year study period, the mean age was 62.6 years, 53.1% were female, and 12.3% contained an ICD-10 diagnosis code indicating MDRO admission prevalence. Of these (n=1,741), 1,341 were documented as MDRO-POA infections, and 256 were documented as carriers or individuals with a known history of an MDRO. From 2015–2023, MDRO admission prevalence among LTCF transfers increased significantly from 6.8% to 14.9% (z=9.3, p<0.0001). Compared to 2016, the odds of MDRO admission prevalence were statistically unchanged for 2017, 2018, and 2019. From 2020-2023 odds increased annually in a dose-response pattern, peaking in 2023 with 58% higher odds compared to 2016 (p<0.001). Conclusions: MDRO prevalence among Arizona LTCF-to-hospital transfers more than doubled from 2015–2023. While pre-pandemic rates remained relatively stable, during the post-2020 period, MDRO admission prevalence increased steadily and significantly. These findings underscore the importance of interfacility communication and health record flagging to accurately capture MDRO prevalence upon admission from LTCFs.

Background: The 2025 Measles outbreak has affected over 1900 people across the United States. Close collaborations between public health entities and training institutions can increase public knowledge and trust, promote vaccination, optimize options for testing, and reduce exposures. Methods: The Lexington Fayette County Health Department (LFCHD), Kentucky Department for Public Health (KDPH), and the University of Kentucky (UKY) partnered in February 2025 to develop a comprehensive plan to address measles in Kentucky. Priorities for the partnership were: community and provider education, delineation of roles/responsibilities between the health department and UKY, streamlined pathways for testing and post-exposure management, and centralized communication. Standardized educational sessions were developed and deployed widely to outline testing and post-exposure prophylaxis (PEP) resources. Infection Prevention and Control (IPAC) physicians triaged all testing requests in partnership with the health department using CDC criteria for testing. Measles, Mumps, and Rubella (MMR) vaccination campaigns were conducted, focusing on prevention and post-exposure management. For healthcare workers (HCW) at UKY, Epic® electronic health record (EHR) templates and order sets outlining CDC and KDPH algorithms were developed and distributed widely. Results: From March through October 2025, the standardized educational talk was given to 398 public health and medical professionals (Table 1). Six public health and healthcare systems adapted the public health-academic center partnership and protocol to their centers (Table 2). Joint media outreach and education resulted in 32 stories across Kentucky and Tennessee. Three Epic® EHR templates were developed and deployed widely (Figures 1-3). IPAC received and triaged approximately 50 calls/EMR messages from HCW about measles testing, resulting in 4 tests performed at the KDPH State Lab. One test returned positive and there were zero healthcare worker exposures. Immune globulin for PEP was offered to 2 exposed patients, though they declined to receive it (Table 2). MMR vaccinations increased by 16% and 53% in the 0-6 year and 6–18-year age groups, respectively from 2024 to 2025, during the same time periods. MMR vaccination in persons over 18 years decreased slightly (4.5%) (Figure 4). Conclusions: Combining the infrastructure, knowledge, and resources of a state and local public health systems with an academic medical center’s training and community trust can increase measles awareness, vaccination, and optimize resources during an outbreak.

Background: Community-acquired pneumonia (CAP) is among the top 10 reasons people seek emergency care and the most common indication for antibacterial use overall. Up to 40% of CAP is caused by viruses, now more easily detectable by rapid diagnostics. Although viral CAP is common, evidence on how to best to treat it is lacking—especially with regard to empiric antibacterials. The 2025 American Thoracic Society guidelines recommend viral CAP be treated with empiric antibiotics. In response, the Infectious Diseases Society of America removed its endorsement of the guideline. Here, we used a vignette survey to assess clinical practices and reasoning regarding early treatment of viral CAP. Methods: Between 10/2025 and 12/2025, we distributed an online clinical vignette survey to attending hospitalists and emergency medicine (EM) physicians from 3 academic medical centers. The vignette described a patient presenting to the emergency department with signs and symptoms of pneumonia (lobar infiltrate, fever, hypoxia) and a positive test for respiratory syncytial virus (RSV). In the survey, clinicians were asked which treatments they would prescribe, their rationale for doing so, and whether clinicians would be willing to enroll a similar patient in a clinical trial examining the need for empiric antibacterial therapy. Results: Respondents included 37 hospitalists and 39 EM physicians (25% response rate, summary in Figure 1). Treatments most commonly selected were supplemental oxygen (93%), inhaled bronchodilators (78%), and empiric antibiotics (63%). Most hospitalists and EM physicians (57% and 69%) selected empiric antibacterial therapy and estimated 72% of their colleagues would also do so. Primary reasons for antibacterial therapy (Figure 2) included covering for a potential bacterial co-infection, evidence suggesting bacterial infection, and local practices. Conversely, physicians who did not select antibacterial therapy favored supportive therapy and observation, interpreted available data as not supporting bacterial infection, and cited local practices. Most (97%) physicians supported enrolling similar patients in a clinical trial examining the need for empiric antibacterial therapy, citing an evidence gap supporting either decision. Conclusions: This vignette survey of EM and hospital medicine physicians showed wide variation in hypothetical use of empiric antibacterials for viral CAP. Factors related to treatment with empiric antibacterial therapy included: 1) covering bacterial infection “just in case” vs. watchful waiting, 2) heterogeneous interpretation of incomplete information as supporting vs. not supporting bacterial infection, and 3) local practice patterns. Most physicians (97%) supported conducting a clinical trial to provide evidence to guide empiric antibacterial therapy in viral CAP.

Background: The accurate monitoring of blood glucose levels is critical in managing diabetes, and the Accu-Chek glucometer is a widely used tool for this purpose. Ensuring the proper cleaning and maintenance of these devices is essential to prevent cross-contamination and ensure reliable readings. This study evaluated the effectiveness of the cleaning process of Accu-Chek glucometers and assessed the competency of healthcare staff in adhering to the recommended two-step cleaning procedure. Methods: A study was conducted within the Audie l. Murphy Memorial Veterans Hospital (ALMMVH), a part of the U.S. Department of Veterans Affairs that provides comprehensive healthcare services to veterans. The VA is one of the largest integrated healthcare systems in the United States, serving millions of veterans annually. A standardized two-step cleaning protocol was implemented, which included an initial wipe with a cleaning solution followed by a disinfectant wipe. Initial compliance was evaluated across 46 clinical areas involving 159 staff members. Staff training sessions were subsequently conducted to educate on the importance and methodology of the cleaning process. Competency assessments were performed: pre- and post-training to evaluate the staff’s understanding and execution of the cleaning procedure. Follow-up evaluations were conducted in 28 clinical areas with 91 staff members participating. Compliance was compared between the pre- and post-intervention periods using the chi-square test. Results: Initial assessments indicated a compliance rate of 55%, with notable variability in staff competency regarding the cleaning process. Post-training evaluations demonstrated significant improvement, with compliance rising to 88% for the two-step cleaning process. (p<0.001 compared to the pre-intervention period). The study observed a significant reduction in the number of dirty machines. Initially, out of 91 machines, 37 were classified as dirty. After implementation of interventions, the number of dirty machines decreased markedly to five out of 57. The comparison of clean machines between pre- and post- periods results in a p-value of <0.0001. The study highlights the effectiveness of training in improving standard operating procedures. Conclusion: The study underscores the critical role of proper training and adherence to cleaning protocols in ensuring the safety and accuracy of blood glucose monitoring. By reinforcing a standardized two-step cleaning process, healthcare facilities can significantly reduce the risk of cross-contamination may enhance reliability of glucometer readings. Ongoing education and competency evaluations are essential to sustain these improvements.

The Hungarian Twin Registry (HTR) has operated as a population-based registry since 2021, following its establishment at Semmelweis University in Budapest. In recent years, the HTR infrastructure has been substantially expanded, including blood storage facilities, information technology systems, a phone bank and voicemail system, and administrative resources. Adult twins (aged ≥18 years) and relatives (parents, foster parents, or caregivers) of twins under 18 years of age can register via the registry’s website or by voicemail following a nationwide identification and notification process. The registration questionnaire consists of eight sections covering sociodemographic and anthropometric characteristics, smoking habits, and medical history, including diseases, surgeries, and therapies. By December 20, 2025, a total of 12,676 twin individuals and their parents or guardians had registered, including 7244 adult twins and 5432 parents or guardians of minors. Based on self-reported data, 44.1% of registered adult twins were monozygotic (MZ) and 55.9% dizygotic (DZ), while among registered children 23.5% were MZ and 76.5% DZ. Of the registered adult twins, 68.4% were female. The HTR offers substantial potential for linkage with national health databases, enabling enrichment of phenotypic and outcome data without additional participant burden. In particular, linkage with the Hungarian National Cancer Registry and other health-related databases is feasible under appropriate ethical approval and data protection procedures and may support long-term follow-up and disease-specific analyses. The article also summarizes current research projects conducted within the HTR, which has become the largest population-based twin registry in Central and Eastern Europe based on the number of registrations.

Background: Antibiotic prescribing varies across communities, and socioeconomic context may influence prescribing patterns. Prior studies have largely relied on aggregate deprivation indices, with limited integration of detailed neighborhood socioeconomic measures and prescriber-level Medicare Part D data. This study examined associations between census block-group socioeconomic characteristics, area deprivation, and antibiotic prescribing rates among Medicare Part D prescribers in Tennessee. Methods: Publicly available Medicare Part D (2023) antibiotic prescriber data were geocoded to exact practice addresses (n = 14,044) and linked to census block-group–level Area Deprivation Index (ADI) scores and socioeconomic indicators derived from the American Community Survey (ACS) 2019–2023 5-year estimates. Predictor variables included ADI decile and block-group measures of education, income, disability, veteran status, Social Security income, vehicle access, and health insurance coverage. Model diagnostics indicated over-dispersion; therefore, negative binomial regression with the logarithm of total claims as an offset was used to model antibiotic claims per prescriber. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) quantified associations. Additional models examined block-group–linked Medicare beneficiary race, ethnicity, and gender composition. Results: Higher ADI scores were modestly associated with increased prescribing (IRR = 1.01, p = 0.03), although this association was attenuated after accounting for rural–urban classification. Income-related indicators demonstrated the strongest relationships: block groups with a higher proportion of low-income residents exhibited substantially increased prescribing rates (IRRs ≈ 1.48–1.62, p < 0.001). Communities with greater reliance on Social Security income also had elevated prescribing (IRR ≈ 1.05, p < 0.001), as did disability prevalence (IRR = 1.06, p < 0.001) and limited vehicle access (IRR = 1.09, p < 0.001). Educational attainment and health insurance coverage were not consistently associated with prescribing patterns. In demographic models, block groups with higher proportions of Black (IRR = 0.92, p < 0.001) and Hispanic (IRR = 0.88, p < 0.01) Medicare beneficiaries were associated with lower prescribing rates, whereas higher proportions of male beneficiaries were associated with increased prescribing (IRR = 1.12, p < 0.001). Conclusion: Community socioeconomic context at the census block-group level was strongly associated with antibiotic prescribing among Medicare Part D prescribers in Tennessee. Income-related factors, disability prevalence, and limited mobility demonstrated the most consistent associations with higher prescribing rates. These findings underscore the importance of incorporating community context into antimicrobial stewardship strategies and support targeted interventions in areas where socioeconomic conditions may influence prescribing behaviors.

Background Illinois has one of the highest regional Candida auris burdens nationwide. Our hospital has a surveillance protocol for Candida auris that dictates all patients with an admission in the prior 6-months to a skilled nursing facility (SNF), long-term acute care hospital (LTACH), and/or inpatient rehab (IR) be tested on hospital admission. Additionally, three high-risk units at our institution have an increased surveillance protocol that includes testing all patients on admission, transfer, and weekly for C. auris. Two years of first-positive C. auris cases were reviewed to investigate if our surveillance protocol was capturing all patients with C. auris present on admission. Method A retrospective chart review was conducted using our electronic database and medical record (EMR). All admitted inpatients between January 1, 2023 to December 31, 2025 with a first-positive Candida auris laboratory specimen were included. Prior positive laboratory tests and outside facility encounters or transfers were manually reviewed from the EMR. Results A two-year data review identified 121 unique patients with positive Candida auris clinical or surveillance results. Of the 121 patients, 99 (81.8%) had no documented history (NDH) or prior positive laboratory results for C. auris. These cases were categorized as hospital onset (HO) 74/99 (74.7%) or present on admission (POA) 25/99 (25.3%). Of the 25 POA/NDH patients, 14 (56%) were directly admitted from a SNF, LTACH, or IR. Of the 25 POA/NDH patients, 17 (68%) had exposure to SNF, LTACH, and/or IR in the 6 months prior to admission. There were 8/25 (32%) patients admitted directly from home or outside hospital (OSH) and had no SNF, LTACH, or IR admissions 6 months prior. These 8 patients did not qualify for surveillance testing when screened for admission. Of the 8 patients, 6 (75%) had an admission to an OSH in the 6 months before surveillance screening. Conclusion The 8 POA/NDH cases without exposure to SNF, LTACH, or IR raise the question of whether including OSH encounters into our screening questionnaire could increase the accuracy of our C. auris surveillance protocol. We have demonstrated that exposure to SNF, LTACH, and IR is a risk factor. Other regional hospitals should be encouraged to evaluate or begin surveillance protocols to help define whether hospital admissions are a risk factor for C. auris acquisition. Validating the accuracy of risk factors will help us better understand the epidemiology of C. auris and potentially prevent HO transmissions from missed POA cases.

Background: Hospital acquired infections are known to increase hospital stays and increase morbidity and mortality. Historically, Methicillin-resistance Staphylococcus aureus (MRSA) screening and contact precautions have been the primary strategy to prevent the spread of MRSA in healthcare systems. Increasing evidence supports the role for MRSA decolonization to decrease the spread of this important pathogen. The COVID-19 pandemic and related personal protective equipment conservation has led to many programs re-examining contact precautions for MRSA. Methods: In February of 2024 MRSA screening was discontinued for new admissions and an MRSA decolonization protocol was implemented for patients at high risk for MRSA infection as defined in the SHEA compendium for reducing MRSA infections. Decolonization included nasal Mupirocin 2% ointment and 2% Chlorhexidine Gluconate (CHG) bathing for five days in the adult inpatient population. High risk patients targeted for this intervention included patients transferred from another healthcare facility, admitted from home health, on dialysis, prior history of MRSA infection or those with central venous catheters. Contact isolation precautions for MRSA colonization were discontinued but maintained for active infection with MRSA. Results: After implementation, MRSA nares screening tests declined by 24.4% while utilization of mupirocin increased 5.85 times the pre-implementation average. In the twelve months prior to the intervention there were 221.1 new MRSA infections per 1000 inpatient admissions and in the 12 months following intervention there were 155.4 new MRSA infections per 1000 inpatient admissions. The rate of MRSA infections had been increasing prior to intervention and the rate of increase decreased by 54.8% after implementation. We estimated a cost savings of $194,745 if all patients that were previously screened were instead decolonized. We additionally noted an approximate 18% reduction in isolation gown use resulting an additional estimated annual cost savings of $115,369 per year if sustained. Conclusions: The implementation of a MRSA decolonization program resulted in significant cost savings without any associated increase in clinical MRSA cultures. The program appeared to have far greater buy-in than the previous screen and isolate program despite having similar patient selection criteria. This may reflect a greater perceived importance of screening relative to a treatment strategy. A decolonization strategy was found to be effective at decreasing the rate of new MRSA infections even with the removal of isolation precautions for colonization. Low compliance with isolation precautions for colonization are thought to be a contributing factor in the limited efficacy of a screen and isolate strategy.

Since the start of Russia’s full-scale invasion of Ukraine in February 2022, Tbilisi has become one of the key destinations of post-2022 Russian emigration. Unlike in many other host societies, this arrival has been met in Georgia with pronounced public resistance, articulated through the language of occupation and anti-imperial refusal. Slogans such as “Russians go home” and references to a “third occupation” translate everyday Russian visibility – language use, spatial clustering, and lifestyle practices – into a historically saturated interpretive framework. This article examines how and why such interpretations have emerged in Tbilisi, and why hostility is frequently directed even at self-identified “good Russians” who oppose the war and the Russian regime. Empirically, the article draws on a mixed-method research design combining long-term ethnographic and digital observation with 30 semi-structured interviews conducted between 2022 and 2024 with young, urban, pro-European Georgians in Tbilisi. Rather than analysing migrants’ intentions or political self-identifications, the study centres the perspectives of the host society and the conditions through which Russian presence is interpreted. Analytically, it adopts a decolonial/postcolonial perspective and mobilises the concept of coloniality to distinguish between historical empire and the persistence of linguistic, cultural, and epistemic hierarchies after its formal end. The findings demonstrate this dynamic.

Background: Feedback reports for medical providers can reduce antibiotic resistance by improving provider antimicrobial prescribing. In 2025, the New York City (NYC) Health Department created and sent antibiotic prescribing feedback reports to a subset of NYC-based primary care providers. Method: We procured 2019– application, a digital platform with antimicrobial stewardship resources. We emailed reports using Public Health Partners Connect, a communication management system. Only providers associated with a NYC address at the time of outreach, with a valid e-mail address, and who had not previously opted out of correspondence with the American Medical Association were included. Result: Of 716 sent reports, 51% (365) were to internal medicine physicians, 16% (114) to family medicine physicians, 14% (100) to physician assistants, 12% (84) to nurse practitioners, and 7% (53) to pediatricians. Of sent reports, 95% (677) were delivered, and 29% (194) of those recipients opened the report. Most who opened reports (83%) had high engagement (<10 seconds). Only one person opted out of receiving future emails, and no complaints were received in response. Conclusion: IQVIA claims data paired with OneKey provider email addresses enabled detailed and specific provider feedback reports on antibiotic prescribing. Including antibiotic appropriateness, duration, and spectrum of activity, rather than volume of antibiotics prescribed alone, allowed us to give providers more robust feedback than would be feasible using only publicly available data. The efficacy of these provider feedback reports could be evaluated with a subsequent data purchase and analysis.

Background: Extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) are a growing public health concern. This study investigates antibiotic resistance patterns for ESBL-E (Escherichia coli and Klebsiella species) cases in Maury and surrounding counties in Tennessee as part of the Emerging Infection Program’s Multi-site Gram-negative Surveillance Initiative. Methods: ESBL-E cases are defined as extended-spectrum cephalosporin-resistant E. coli, Klebsiella pneumoniae, Klebsiella variicola, or Klebsiella oxytoca isolated from urine or normally sterile sites from residents of the surveillance area. Cases from July 2019 through December 2024 were included. Susceptibility data were collected from clinical laboratory reports. E. coli isolate resistance was compared to aggregated Klebsiella species isolate resistance using χ or fisher’s exact tests. Organism specific yearly resistance trends excluded the incomplete 2019 collection year and were examined via simple linear regression. Analyses were performed in SAS 9.4. Results: We identified 2,206 isolates including 1,915 E. coli isolates, of which 1,868 (97.5%) were from urine, and 291 Klebsiella isolates, of which 281 (96.6%) were from urine. Overall percent resistance for selected antibiotics were as follows: ciprofloxacin: 69.0%, levofloxacin: 64.3%, cefepime: 81.1%, cefazolin: 98.7%, cefotaxime: 85.9%, ceftazidime: 53.2%, ceftriaxone: 92.8%, piperacillin-tazobactam: 2.6%, nitrofurantoin: 9.0%, trimethoprim-sulfamethoxazole: 57.8%. During the study period, E. coli isolates displayed increased resistance to cefepime (3.0% per year, P<0.001), ceftriaxone (1.3% per year, P:P: 0.02); Klebsiella isolates demonstrated increased resistance to levofloxacin (5.9% per year, P: 0.002) and cefepime (5.7% per year, P: 0.003). Over the study period, E. coli isolates displayed higher rates of resistance than Klebsiella isolates to ciprofloxacin (74.0% vs. 36.4%, P<0.001), levofloxacin (71.4% vs. 19.0%, P<0.001), cefotaxime (87.0% vs. 79.0%, P<0.001) and ceftriaxone (93.5% vs. 87.9%, P<0.001). Klebsiella isolates had higher resistance to ceftazidime (59.9% vs. 52.1%, P: 0.01), piperacillin-tazobactam (8.9% vs. 1.6%, P<0.001), nitrofurantoin (18.6% vs. 7.6%, P<0.001), and trimethoprim-sulfamethoxazole (68.6% vs. 56.1%, P<0.001). There were no significant differences in resistance to cefepime or cefazolin between groups. Conclusion: In our data, ESBL-E pathogens demonstrated trends of increasing resistance to certain antibiotics over time. There were significant differences in resistance between species within different classes of antibiotics. These data support the idea that organism type is important for determining the best antibiotic for empiric treatment. Continued monitoring of antibiotic resistance in ESBL-E is imperative to understanding changes in antibiotic resistance patterns. The increasing trends in proportion of antimicrobial resistant strains warrants strengthening antimicrobial stewardship and infection prevention programs within the surveillance area.

Background: Resilient healthcare systems prevent, absorb, and learn from stressors. Identifying resilient performance in healthcare systems can be challenging due to complex underlying processes and associated outcomes. This study aimed to identify resilient performance in US outpatient hemodialysis (HD) facilities during the COVID-19 pandemic by characterizing associated operational factors and classifying longitudinal patterns in bloodstream infections (BSI) rates using machine learning. Methods: This study used longitudinal BSI data reported to National Healthcare Safety Network (NHSN) by outpatient HD facilities during pre-pandemic (April 1, 2018–April 30, 2019) and pandemic (April 1, 2021–April 30, 2023) periods. For each period, facilities were classified into distinct patterns based on facility-level BSI rates (cases per 100 patient months) using k-means clustering for longitudinal data (KmL), an unsupervised machine-learning method. CMS Dialysis Facility data provided key facility characteristics and NHSN Annual Dialysis Facility Surveys provided use of Core Interventions for Dialysis BSI Prevention. Facility resilience was operationalized as classification in a lower BSI rate cluster during the pandemic period. Associations between KmL classification during the pandemic and facility operational factors were assessed using multivariable logistic regression. Result: Of 7084 outpatient HD facilities, 4907 (69%) reported BSIs to NHSN during both periods and linked to CMS data. KmL grouped facilities into two clusters for each period. During the pandemic, a lower-rate cluster (n=4132, 84%) and a higher rate cluster (n=775, 16%) had mean BSI rates of 0.19 and 0.76 per 100 patient-months, respectively. Both clusters reported strong implementation of Core Interventions; however, the higher-rate cluster had increased odds of implementing ≤64% of interventions. In the multivariable model, facilities in the higher-rate pandemic cluster were associated with being in the higher-rate pre-pandemic cluster, structural factors (non-profit ownership, non-chain facility status, having <20 dialysis stations), processes (increased central vascular catheter use, lower use of antiseptic-impregnated catheter end caps, rarely administering antibiotics before obtaining blood cultures for suspected BSIs), and geography (Northeast or Midwest US location, rurality). Conclusion: Using machine learning, two distinct BSI rate trajectories emerged before and during the COVID-19 pandemic, with key operational differences between facility groups. Facilities demonstrating lower and stable BSI trajectories during pandemic could be interpreted as exhibiting more resilient performance under system stressors. This approach can inform resilient performance across other patient safety processes, healthcare settings, and system stressors. Understanding structures and processes associated with patient safety outcomes during disruption can support public health prioritization and targeted interventions to strengthen healthcare system resilience.

Introduction: NDM-producing Carbapenem-resistant Acinetobacter baumannii (CRAB) is an emerging concern globally due to extensive antimicrobial resistance and high mortality, although less common in the United States. We describe the epidemiology of this pathogen at our academic medical center over a 5-year period. Methods: Observational study and epidemiologic investigation at two campuses (800-bed hospital (“A”) including 7 adult ICUs and 144-bed hospital (“B”) including 1 ICU and 1 long-term post-acute unit) with patient-sharing. Patients with CRAB in clinical or surveillance cultures from January 2021 to April 2025 were included. Active surveillance was conducted in select units using rectal swabs, and available isolates underwent genomic sequencing. Results: We identified 13 unique patients with 61 NDM-CRAB clinical (7 [11%]) or surveillance (54 [89%]) cultures. Two of 10 colonized patients subsequently developed clinical infection. NDM-CRAB constituted 25% of all sequenced CRAB isolates during this time. Among the 13 patients, median age was 62 years, 6 (46%) were female, all had prior healthcare exposure and 10 (77%) had colonization or infection with other multidrug-resistant organisms (MDROs). None reported international travel. Nine patients (69%) had prior exposure to carbapenems, 9 (69%) had central venous catheters, and 7 (54%) required mechanical ventilation. Sites of infection included pneumonia, urinary tract, and wound. Following sporadic cases from 2021-2023, a cluster of 2 cases occurred on the post-acute unit in 2024 followed by a prolonged outbreak (n=10) detected via weekly rectal surveillance cultures (Figure). With the exception of the index case, all other post-acute unit outbreak cases had a prior negative surveillance screen, suggesting transmission among long-stay patients. Observations revealed suboptimal environmental surface-cleaning and deficiencies in use of personal protective equipment. No additional cases were identified on other units including ICUs undergoing routine weekly surveillance. Twenty-five NDM-CRAB isolates underwent genomic sequencing. All belonged to the same A. baumannii multilocus sequencing typing (MLST) lineage (STPas2, STOxf 218/2164). Long-read sequencing of select isolates identified blaNDM-1 and blaOXA-23 integrated in the chromosome. Notably, one isolate additionally acquired blaOXA-72 on a r3-T60 Acinetobacter plasmid, suggesting continuing genetic evolution. Conclusion: Over a 5-year period, we found NDM-CRAB transmission in a post-acute care unit within an acute care hospital, among long-stay patients with invasive devices and antibiotic exposure. We did not observe sustained transmission in other parts of the hospital, underscoring the contribution of long-term acute care in MDRO dissemination. Genomic analysis helped distinguish this cluster from other non-NDM CRAB cases, supplementing epidemiologic findings.

Background: Candida auris (CA) poses an urgent public health threat due to its multidrug-resistance, associated mortality, and ability to persist in the inanimate healthcare environment. We sought to ascertain factors associated with a prolonged multi-facility outbreak that was not amenable to previously successful containment measures involving Clade 1. Methods: Contact tracing and testing, environmental sampling, cleaning observations with intensified cleaning, and whole genome sequencing were performed. Additionally, dry hydrogen peroxide units (Synexis DHP® Overland Park, KS) were installed, damaged furniture was replaced, and availability of dedicated equipment was increased. Standard urine culturing protocols were changed to better detect and identify yeast. Exposed patients that remained uncolonized were compared to exposed colonized patients in a nested case control exploratory analysis using multivariable logistic regression with excess antibiotic days as the primary exposure in the adjusted model. Covariates were selected based on prior understanding of the pathogen, biological plausibility, and univariable analyses to explore crude associations. We created one primary adjusted model, with additional sensitivity analyses conducted to avoid overfitting due to the small sample size and potential confounding. Model discrimination was evaluated using the area under the curve. Results: All isolates in the initial clusters were Clade III and highly genetically related to each other. Later a small cluster of highly related Clade 1 emerged. Patient variables and descriptive statistics appear in Table 1. After adjusting for age, sex, number of rooms the patient occupied, and Charlson comorbidity score, each additional day of unjustified antibiotics prior to culture was associated with a 63% increase in the odds of CA positivity (OR=1.63 per day, 95% CI: 1.22-2.53, p=0.007). Number of patient rooms occupied prior to culture was also strongly associated with positivity (OR=1.83 per additional room, 95% CI 1.37-2.82, p=0.0007). Discussion We applied the same containment measures that had previously succeeded, along with those described above, but were unable to control this outbreak. At the time of this submission, CA continued to be detected sporadically in clinical cultures, supporting our hypothesis that clade III is more difficult to contain than Clade I. This report is notable because it confirms our earlier findings of CA emergence linked solely to excess antibiotic exposure, using a more robust study design. As excess antibiotic days was independently associated with CA positivity, it underscores the importance of aggressive antimicrobial stewardship to prevent emergence. Once CA establishes itself, containment may be impossible.

Background: Inpatient psychiatric units (IPUs) present unique challenges for prevention of respiratory virus illness (RVI) transmissions due to shared living spaces, group-based therapeutic activities, and limited ability to isolate or mask patients. Evidence-based infection prevention (IP) strategies in these settings are limited. We evaluated trends in hospital-onset (HO) RVIs on an IPU across pre-pandemic, pandemic, and post-pandemic masking eras and describe implementation of a unit-specific RVI mitigation playbook. Methods: We conducted a retrospective review of respiratory viral testing on the IPU from January 2018 through December 2025 at a 943-bed academic medical center. The IPU is comprised of 25 private rooms, two semi-private rooms, and shared common areas. Respiratory viral testing was performed on a reverse-transcriptase polymerase chain reaction (RT-PCR) assay (BioFire Respiratory Pathogen Panel, BioFire, Salt Lake City, UT or Xpert® Xpress CoV-2/Flu/RSV plus, Sunnyvale, CA) utilizing a nasopharyngeal swab. Patients were tested for respiratory viruses prior to IPU admission beginning March 2020 regardless of symptoms. Patients with positive results were not admitted to IPU due to the inability to accommodate isolation. Following a SARS-CoV-2 outbreak on the unit in December 2021-January 2022, a psychiatry-specific HO-RVI mitigation playbook was implemented to define response thresholds (Figure 1). HO-RVI was defined as symptom onset and/or a positive test occurring more than 48 hours after admission, with classification informed by virus-specific incubation periods based on published literature. A cluster was defined as two epidemiologically linked positive tests, including patient–patient or patient–healthcare worker combinations. An outbreak was defined as three or more patients and/or healthcare workers with HO-RVIs whose epidemiology indicates shared time and space. Results: On the IPU, HO-RVIs occurred sporadically (Figure 2). Since January 2022, no RVI outbreaks have occurred on this unit, despite periods without universal masking, continued identification of HO cases, and mitigation of seven RVI clusters. SARS-CoV-2 accounted for the majority of identified cases, though most were asymptomatic and detected through routine pre-procedural electroconvulsive therapy testing, without progression to outbreaks. Conclusions: Sustained prevention of RVI outbreaks on an IPU is achievable despite ongoing viral circulation and limited feasibility of patient isolation or masking. A tailored mitigation playbook incorporating early identification of cases and thresholds for implementing IP interventions may reduce outbreak risk while preserving the therapeutic milieu. These findings support development of setting-specific IP strategies for inpatient psychiatric environments. Additional studies are needed to inform best practices for preventing RVI transmissions in these settings.

The concept of protopia, coined by Kevin Kelly, was introduced as an alternative to utopian and dystopian thinking, framing progress as incremental improvement rather than an idealized end state (Kelly 2016). In The Inevitable, Kelly describes protopia as a condition of continual becoming—futures that are “better today than yesterday”— emerging largely through cumulative technological development. More recent reinterpretations, including those advanced by Monika Bielskyte and the Protopian Futures collective, have expanded protopia beyond technological emergence toward pluralistic, ethical, and culturally grounded imaginaries (Bielskyte 2021). This work productively recenters values, inclusion, and alternative worldviews, while often operating upstream of technical specification, leaving open questions about how such imaginaries interface with concrete scientific research trajectories, deployment constraints, and governance mechanisms.

Background: Outpatient Parenteral Antimicrobial Therapy (OPAT) moves specialized, technically demanding care from hospitals to homes, where patients and caregivers take on tasks performed traditionally by trained nurses. However, infection prevention research rarely examines the home environment where OPAT administration and intravenous (IV) line management increasingly occur. Standard quantitative and qualitative approaches (e.g., surveys, interviews) may miss subtle medication administration deviations, environmental constraints, and other challenges that influence IV catheter- and medication-related risks. Video Reflexive Ethnography (VRE) and Photo Elicitation Interviews (PEI) offer a way to observe medication administration processes directly and to incorporate patient and caregiver perspectives to improve infection prevention education and practices. Methods: Using a VRE approach, we videorecorded discharge teaching and in-home OPAT routines, then conducted reflexive sessions in which patients and caregivers reviewed their own discharge teaching videos and discussed aspects of the process they found helpful, unclear, or challenging within their home environments. PEI added a participant-driven perspective by inviting patients and caregivers to photograph features of their home care setup that facilitated or hindered antibiotic administration and IV handling. Figure 1 demonstrates the steps in data collection. The Systems Engineering Initiative for Patient Safety Results: Observations of four patients, both in hospital and at home, revealed that visual methods captured behavioral details (e.g., using teeth to open syringe packaging) not typically discussed in interviews. Reflexive sessions and photo elicitation interviews highlighted uncertainties (e.g., doubts about correct processes), challenges with medication or IV-line maintenance (e.g., difficulty with IV clamps), and practical strategies for managing complex care tasks at home (e.g., hanging IV bag from wall hook rather than IV pole). These methods provided deeper insights into patients' experiences with care. Conclusions: This study demonstrates how VRE and PEI used together can strengthen infection prevention research. Both methodologies in concert provide new insight into how real-world patient and caregiver behaviors, constraints, and teaching gaps shape IV-line care, medication administration, and overall safety outside the hospital. By providing a clearer view of OPAT-related care as it occurs in home settings, this work shows promise for informing future refinement of education and IV medication administration guidance. This work is especially relevant given the growing complexity of infection-related care, including care delivered outside the hospital setting, requiring new approaches to understand and support patient safety.

Background: Antimicrobial overuse increases antimicrobial resistance and adverse effects. Most antibiotics are prescribed in the ambulatory setting and up to half are inappropriate. We investigated the effect of a bundled stewardship intervention with active audit and feedback on antibiotic duration for two common infections, community acquired pneumonia (CAP) and skin and soft tissue infection (SSTI), in adult outpatients. Methods: From 2019-2021, institutional guidelines for management of CAP and SSTI were developed, and a dashboard to passively report data on provider-level antimicrobial durations for CAP and SSTI was created. From 2022-2023, clinical decision support tools promoting guideline-concordant antibiotic durations for both infection types were created in the Electronic Health Record. Education across all provider groups was completed throughout 2023. In the second quarter of 2023, personalized provider feedback reports (figure 1) on antimicrobial duration for CAP and SSTI were provided quarterly via electronic mail to individual providers. We performed an interrupted time series analysis of adult patients (age ≥21) prescribed an enteral antibiotic for CAP or SSTI within 3 days of a primary care encounter. The intervention period began one quarter after feedback was initially provided. Prescriptions of <3 days or <14 days were excluded as unlikely to represent uncomplicated infection. The primary outcome was proportion of patients prescribed appropriate antibiotic durations, defined as ≤5 days for CAP and ≤7 days for SSTI. Results: Eighteen quarters of data were analyzed (9 pre-intervention and 9 post-intervention). For SSTI (figure 2), there was no pre-intervention change in appropriate duration (p = 0.746). After intervention, there was an immediate increase in absolute proportion of appropriate antibiotic duration of 6.8 percentage points (p=0.009) with an ongoing increase of 1.25 percentage points each quarter (p=0.001). For CAP (figure 3), there was no pre-intervention change in appropriate duration (p = 0.44). There was no immediate change in absolute proportion of appropriate antibiotic duration (2.4%, p=0.698). After intervention, there was an ongoing increase in appropriate antibiotic duration of 2.69 percentage points each quarter (p=0.006), though not significantly different than the pre-intervention trend (p = 0.096). Conclusion: Clinician audit and feedback significantly improved antibiotic duration appropriateness for SSTI both immediately and progressively after implementation. Appropriate antibiotic duration for CAP also improved over time, though this was not significantly different than the pre-intervention trend. Active, individualized feedback to providers may be an effective strategy to improve appropriate antibiotic durations in ambulatory CAP and was an effective strategy for SSTI.