This paper investigates variation in the realization of the happy vowel in Manchester, England, that is, the final vowel in happy, baby, etc., which is often described as extremely lax. It is based on the acoustic analysis of 109 speakers, stratified for age, gender, social class, and ethnicity. The vowel is a rarely reported case of a stable vocalic variable, with no change in apparent time but with clear conditioning by social class (with higher social classes having tenser vowels) and by ethnicity. Style-shifting is minimal, statistically insignificant, and appears to result from durational effects; we conclude that the variable lies largely below speakers’ conscious awareness within the speech community. We explore the long-standing Labovian hypothesis that internal linguistic constraints operate independently of social factors and find that the results largely support this hypothesis for the happy vowel. This suggests a shared underlying system despite social differentiation in overall vowel realization.

Background: The U.S. is on track to lose measles elimination status after experiencing the highest number of cases in <30 years. With ongoing transmission and falling vaccination rates, health systems must prepare for measles, focusing on minimizing secondary cases and maximizing prevention. We describe a taskforce approach for comprehensive measles (with a lens towards all-hazard)preparedness across our enterprise. Methods: Our mitigation and preparedness taskforce included four workstreams (Figure 1): Early MMR vaccination for children with international travel: Consistently offer and administer initial or second MMR vaccine, as appropriate, for infants and children travelling abroad. Optimize exposure and testing management: Develop tools to expedite the identification of exposed non-immune patients and optimize processes for high volume testing and result tracking. Optimize screening processes at points of entry (POE): Develop streamlined processes for reliable travel and exposure screening at all enterprise wide POEs. Contingency planning for larger scale exposure events/community spread: Develop post-exposure prophylaxis (PEP) delivery procedures to respond to large-scale community exposure events and establish partnerships with local public health (PH) departments. Results: Increase in vaccination for non-immune travelers in primary care: We built an EMR (electronic medical record) prompt into all child visits to screen for travel, which interfaced with vaccine clinical decision support to offer/administer vaccines. From May through 12/28/25 we administered 1325 early MMRs to travelling children (Figure 2). EMR-based report to identify exposed individuals and their immune status: This report allows all sites to rapidly identify patients needing PEP after exposure. We also developed processes for pre-emptive approval for large scale testing, result tracking, and high-volume patient notification. Optimization of Screening and POE with EMR upgrades, PPE kits: We are upgrading our EMR to better integrate travel & exposure screening. We developed additional resources including screening supports for non-English languages and PPE kits for immediate use at POE when patients screen positive. Development of PEP clinics and PH Collaboration: We developed processes to stand up PEP clinics at our hospitals to expedite large volume PEP administration. We worked with PH to outline roles, capabilities and resources for response to community outbreaks, optimized staff fit testing and developed drills across all care settings. Conclusions: Preparedness for highly contagious infectious diseases and emerging PH threats is critical. A taskforce approach provides a structured framework for collaboration and mobilization of resources. By utilizing an all-hazards lens, this framework is broadly applicable for vaccine preventable infections and other infectious threats.

Background: Carbapenemase-producing organisms (CPOs) can cause serious, difficult-to-treat infections and spread rapidly in healthcare settings. Although pediatric CPO cases are uncommon, they may be increasing in the United States. We describe CPO surveillance practices and patient and specimen characteristics among patients admitted to a California pediatric specialty hospital that regularly receives high-acuity patients referred from healthcare facilities outside the US. Methods: Carbapenem-resistant organisms identified from clinical specimens underwent molecular testing to identify the “big-5” carbapenemases (i.e., KPC, NDM, OXA-48 like, VIM, IMP); carbapenem-resistant Acinetobacter baumannii (CRAB) isolates were also tested for additional oxacillinase (OXA) variant carbapenemases at a public health laboratory. In August 2024, the hospital began screening patients upon admission from non-US healthcare facilities by collecting rectal swabs for molecular testing for big-5 carbapenemases, and culture-based screening for CRAB with molecular testing to identify the big-5 and additional OXA variant carbapenemases. We collected patient and specimen data from the hospital and public health case reports. We defined a case as carbapenemase(s) detected in a clinical or screening specimen from a pediatric patient (ages 1–18 years), either during admission or within 3 days of transfer from the hospital from January 2022 to August 2025. Result: Among 28 total cases, 17 (61%) were in clinical specimens (10 wound, 3 blood, 3 respiratory, and 1 tissue) and 11 (39%) in 34 rectal swab specimens (32% positivity) collected through admission screening starting in August 2024 (Figure 1). The most common carbapenemases were OXA-23-like (32%) and OXA-24/40-like (32%) and the most common organism was A. baumannii (79%). Of the 27 patients (one had two cases), the median age was 11 years; 20 (74%) were Hispanic and 21 (78%) were non-US residents. Twenty-two (82%) were admitted for burn injuries and 24 (89%) had international healthcare exposure. Conclusion: Admission screening based on international healthcare exposures had a high (32%) yield and identified more than half of all CPO cases since implementation. The majority of CPO cases were OXA variant-producing CRAB, highlighting the role of culture-based screening to identify carbapenemase-producing CRAB that otherwise would not be detected by screening with molecular testing for big-5 carbapenemases only. Risk-based admission screening is a key component of a comprehensive CPO prevention strategy by facilitating rapid detection of cases and timely implementation of focused infection prevention and control measures to prevent further spread among a vulnerable population.

Current wound closure methods have drawbacks when used in minimally invasive surgery. Traditional sutures are complicated and time-consuming to apply in this context, and synthetic adhesives can be toxic when used internally. The class of bioadhesives address these challenges, however their independent use in practice is limited due to their low tensile strength. In this work, we develop Kelserra, a novel bioadhesive derived from brown algae with maximized tensile strength and biocompatibility to address a current unmet need in the surgical field. Kelserra’s uniaxial yield stress peaked at 7.19 ± 0.47 kPa when the formulation contained 50 mg/mL alginate, 5 mg/mL phloroglucinol, 10 mg/mL xanthan gum and 2.09 mg/mL Ca-EDTA and was pre-cured using saturated aqueous gluconic acid for 45 minutes. Kelserra’s uniaxial strength was higher than its lap shear strength when pre-cured. Additionally, the type of curing medium (air or PBS) did not significantly influence adhesive strength. This study is intended as a preliminary work inquiring into the possibility of the exploration of internal bioadhesives such as Kelserra, and further validation is required for translational applications. Internal bioadhesives like Kelserra could decrease surgery times, aid in the prevention of postoperative complications and reduce the burden on the healthcare system.

Background: Previous studies demonstrated that the addition of anterior nares to axilla/groin skin testing substantially improved the detection of Candidozyma auris colonization (Proctor et al., Nature Medicine, 2021; Sansom et al., CID, 2024), but these observations were limited by small sample sizes and reflected mostly nursing home residents. We aimed to assess the benefit of adding nares testing to axilla/groin testing among hospitalized patients participating in C. auris point prevalence surveys (PPSs). Methods We conducted a prospective observational study at three long-term acute care hospitals (LTACHs) in the Chicago region, one of which also included distinct inpatient rehabilitation floors. Facilities participated in quarterly public health-led C. auris PPSs from May 2024 to October 2025. Patients underwent swab sampling at two sites: composite bilateral axillae/groin (swab 1) and bilateral anterior nares (swab 2). Samples were processed at a central laboratory for C. auris detection by PCR using a validated assay with enzymatic preprocessing and automated DNA extraction. Primary analyses were restricted to patients with results available from both sampling sites; a positive C. auris test from either body site was considered the reference standard. Analyses were performed using R v4.5.2 (www.r-project.org) and Stata/SE v18.0 (Stata Corp., College Station, TX). Results Across 18 PPSs, 769 of 867 (89%) eligible patients participated. The overall C. auris prevalence was 46% (317/685) among LTACH patients and 15% (13/84) among rehabilitation patients. Among all patients who tested positive for C. auris, 64% were in Contact Precautions for any reason at time of PPS and 34% were previously known to be C. auris colonized. After excluding 16 patients who were missing a body site specimen, 753 patients were eligible for analysis (670 LTACH, 83 rehabilitation). Among 320 patients with C. auris detected at any body site, 301 were detected by axilla/groin screening (94% sensitivity; 95% confidence interval 91% to 96%) and 234 (73%) tested positive at the anterior nares for C. auris. Inclusion of nares swabbing identified 19 additional patients who would have been missed by axilla/groin screening alone, corresponding to an incremental increase of 6%. Conclusion Among LTACH and rehabilitation patients, C. auris colonization was common and PPSs identified a substantial number of patients not previously known to be colonized. The incremental benefit of adding nares screening was modest compared to axilla/groin screening alone. Testing more body sites can identify more C. auris colonized patients, but facilities should balance benefit versus cost of expanded screening approaches.

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.