Background: Patients undergoing hepato-pancreato-biliary (HPB) surgery routinely need central venous access for chemotherapy or parenteral nutrition. Common postoperative complications of HPB surgeries include cholangitis and transient bacteremia from biliary tract manipulation. Previous studies have suggested that the National Healthcare Safety Network (NHSN) criteria that designate bacteremia secondary to infections such as cholangitis, may be too strict to account for these situations, resulting in central line associated bloodstream infection (CLABSI) misattribution. Methods: This retrospective study evaluated bacteremia events within 30 days of an HPB surgical procedure among patients ≥ 18 years old at a large academic medical center in the United States. The study period included January 1, 2024 through October 31, 2025. HPB procedures were identified using operative codes mapped to HPB surgeries by NHSN with bacteremia cases identified electronically. CLABSI cases, as established by NHSN criteria, underwent manual chart review to understand the clinical context. Results: There were 1,143 HPB surgeries within the study period. Bacteremia was detected in 35 of them (3.1%). Five of these were ruled in as CLABSI. CLABSIs occurred at an average of 9.6 days postoperatively and 7.6 days after central line placement or access. CLABSIs were due to Enterococcus faecalis, Candida krusei, Prevotella species, Klebsiella oxytoca, and Staphylococcus aureus. Three of the CLABSIs had clinical evidence of cholangitis, but imaging findings were insufficient to meet NHSN criteria for an intraabdominal infection. These cases included transient bacteremia within 24 hours of biliary manipulation (drain placement for a portobiliary fistula, n=1, and drain capping, n=2). The other two CLABSI cases did not undergo biliary manipulation during their hospitalization and had no clear evidence of secondary infection. Conclusion: A substantial number of CLABSIs in HPB surgical patients may represent misattribution. Consideration to the unique infection risks of HPB surgical patients such as transient bacteremia related to drain placement and exchange could minimize CLABSI misattribution in this patient population. Ellsworth, M. G., Ausborn, V., Patel, B., Chang, P., & Ostrosky-Zeichner, L. (2023). 2419. Increasing Misattribution of Bacteremia as CLABSIs by NHSN Definitions: A Tertiary Care Center Perspective. Open Forum Infectious Diseases, 10(Suppl 2), ofad500.2039. https://doi.org/10.1093/ofid/ofad500.2039

Background: Inappropriate urine culture ordering in hospitalized patients with indwelling urinary catheters contributes to unnecessary antibiotic exposure and increased risk of catheter-associated urinary tract infections (CAUTI). Urine Culture Stewardship Interventions have emerged as strategies to reduce unnecessary urine culture testing and downstream antibiotic use; however, the magnitude of their impact across clinical settings remains incompletely characterized. Methods: We conducted a scoping review following PRISMA-ScR guidelines to identify studies evaluating urine culture stewardship interventions in hospitalized adults (≥18 years) with indwelling urinary catheters. A systematic literature search was performed in PubMed, Cochrane Library, Web of Science, and Scopus from inception through June 2025, using predefined terms related to indwelling urinary catheters, urinary tract infections and CAUTI, urine culture and diagnostic stewardship, antibiotic use, and catheter management strategies. Interventions included reflex urine culture protocols, catheter replacement prior to specimen collection, educational initiatives, and multicomponent stewardship bundles. Outcomes of interest were urine culture utilization, CAUTI rates, and antibiotic utilization. Data were extracted independently by two reviewers using Covidence. Results were synthesized descriptively, and ranges of relative change were calculated by the review authors when pre- and post-intervention rates were explicitly reported. Results: Conclusion: Urine culture stewardship interventions in hospitalized adults with urinary catheters are consistently associated with meaningful reductions in urine culture utilization and CAUTI rates, with variable but generally favorable effects on antibiotic use. Education-based and reflex urine culture strategies, particularly when embedded within multicomponent stewardship bundles, appear most frequently studied and effective. These findings highlight the potential of diagnostic stewardship as a key component of infection prevention and antimicrobial stewardship efforts, while underscoring the need for standardized outcome reporting and to better quantify downstream clinical impact.

Background: Carbapenem-resistant organisms (CRO) and Candida auris are multidrug-resistant organisms (MDRO) that can spread between patients and environments, posing a threat to health care systems, including acute care hospitals and nursing homes. However, their impact on non-nursing home congregate residential facilities, such as homeless shelters and assisted living facilities, is poorly understood. These facilities traditionally lack infection prevention and control (IPC) capacity as compared with health care facilities, have multi-occupancy rooms, and may have high censuses, all of which facilitate disease spread. Methods: To inform opportunities for public health intervention, clinical CRO and C. auris cases were enumerated from results reported to the New York City Health Department during 2019–2024. Patients’ geocoded addresses were matched to a list of non-nursing home congregate residential facilities. Cases were counted once during the study period, in alignment with the 2023 Council of State and Territorial Epidemiologists Carbapenemase-Producing Organisms and C. auris case definitions. CRO cases were counted separately for each organism/carbapenemase combination among patients where multiple combinations were reported. Cases’ demographic, isolate, and residential facility characteristics were summarized using univariate statistics. Results: During 2019–2024, 97% (11507/11858) of CRO and 100% of 1848 C. auris cases were reported with complete addresses. Of those, 471 (4%) CRO and 89 (5%) C. auris cases’ addresses matched a non-nursing home congregate residential facility at the time of diagnosis. Most CRO (63%) and C. auris (70%) cases were male. The median age at diagnosis for CRO cases was 64 years (interquartile range: 52–100 years) and for C. auris cases was 60 years (interquartile range: 51–69 years). Most laboratory tests originated from inpatient facilities for both CRO (65%) and C. auris (71%) cases. Among CRO and C. auris cases whose addresses matched to a congregate setting, the most common non-nursing home congregate facility types were group homes for people with intellectual and developmental disabilities (33% and 38%, respectively), shelters for people experiencing homelessness (25% and 26%), assisted living facilities (22% and 15%), and housing for people with mental health conditions (14% and 18%). Conclusion: More research is needed regarding CRO and C. auris in congregate settings. People residing in these environments may benefit from tailored approaches to MDRO case management. Enhanced surveillance by health departments in the form of routinized geocoding and address matching, which is low-cost and uses existing data sources, can identify facilities that could benefit from IPC support, education, and resource distribution.

Background: Over the past decade there has been an increased focus on infection prevention in post-acute care settings, including long-term care (LTC), skilled nursing facilities (SNF), rehabilitation facilities and home health. Many of these settings provide care for older people with complex care needs. Research has shown high rates of inappropriate antibiotic prescribing, with sub-optimal drug choice, dosing and duration – all targets for antimicrobial stewardship programs (ASP). Although national guidance is available, implementation remains challenging. In this study, we explored the structure and leadership of ASP in a variety of post-acute care settings from an infection prevention perspective. Methods: Infection Preventionists (IPs) were invited to participate in the 5-yearly Association for Professionals in Infection Prevention (APIC) Megasurvey. The electronic survey was advertised using snowball recruitment by APIC between June 6 and July 31, 2025. Data were collected on ASP characteristics, including structure and leadership of programs, and resources available to support appropriate prescribing. Descriptive statistics were used to summarize the data. Results: A total of 489 respondents reported working in post-acute settings. Of these 239 (49%) worked in long term care, 200 (41%) in skilled nursing facilities, 26 (5%) in inpatient rehabilitation and 24 (5%) in home health. Facility-based post-acute care IPs overwhelmingly reported the existence of ASPs (LTC-82%; SNF/Rehabilitation – 93%) with a committee having oversight (LTC-86%; SNF/Rehabilitation – 80%). This governance function was often incorporated into infection prevention committees (LTC - 52%; SNF/Rehabilitation – 43%). In LTC, ASPs were led by a range of healthcare professionals including IPs (27%), infectious diseases (ID) physicians (10%), ID pharmacists (10%), pharmacists (non-ID) (23%), and other medical professionals such as internists (22%). In SNFs/ Rehabilitation facilities, a similar pattern was observed. IPs reported they had up-to-date recommendations available for infection management (LTC - 88%, SNF/Rehabilitation -83%), and around half also noted existence of regular rounds to allow inquiry about appropriate antibiotic prescribing (LTC - 52%, SNF/Rehabilitation - 53%) Only 29% of IP respondents from home health reported having an ASP. Although numbers are small, it appears that 70% of these programs had the governance of an ASP Committee but there was little IP involvement in leadership or antibiotic prescribing review activities. Conclusion: This study provides unique insights into ASP in post-acute care. Programs are now well-established in many facility types. More work is needed to understand and help IPs develop ASP expertise relevant for post-acute settings, particularly in home health.

This study investigated the size and distribution of university-based journals published in federal universities of North-Western Nigeria. Using an exploratory descriptive survey design, data were gathered from institutional lists, university websites, and physical serial holdings in libraries of the universities. A total of 243 journals were identified across ten universities, with Ahmadu Bello University, Zaria, Bayero University, Kano, and Usmanu Danfodiyo University, Sokoto collectively accounting for more than half of the total. Social sciences, arts, and humanities dominated the disciplinary distribution, while STEM, health sciences, and agriculture accounted for smaller shares. An important finding was that most university libraries did not maintain complete holdings of the journals published in the parent institution, revealing weaknesses in distribution strategy, bibliographic control and preservation. The study concludes that although journal proliferation is evident, visibility and long-term archiving remain problematic. It recommends the establishment of institutional and national journal registries, stronger archiving practices, and total migration to digital platforms to enhance access and global recognition of the journals.

Background: Social deprivation may affect both infection severity and the quality of antibiotic prescribing, but its influence on downstream outcomes and the role of stewardship processes in this pathway remain uncertain. Methods: We conducted a retrospective cohort study of 1,365,957 emergency department (ED) encounters among older adults across multiple U.S. hospitals, 2013–2022. We assessed the impact of community social deprivation on clinical outcomes and identified mediation through antibiotic prescribing (guideline-concordant empiric use). Social deprivation was quantified using a z-scored Social Deprivation Index (SDI). Outcomes were log-transformed length of stay (LOS), 30-day ED revisit, 30-day mortality, 30-day C. difficile infection, and DOOR (Desirability of Outcome Ranking; 1=alive with LOS at or below the median and no 30-day events, 2=alive with LOS above the median and no events, 3=30-day ED revisit, 4<=i>C. difficile infection, 5=death). We fitted multivariable ordinary least squares models with state- and month-fixed effects and clustered standard errors, controlling for demographics, comorbidities, clinical severity, travel time, hospital characteristics, and rurality. We applied regression-based mediation analysis to partition the SDI–outcome relationship into direct effects and indirect effects mediated by prescribing concordance. Secondary models substituted antibiotic overuse or underuse for concordance. Results: Concordant prescribing occurred in 83% of encounters; overuse and underuse occurred in 9.5% and 7.4%, respectively. Higher SDI was associated with slightly worse outcomes: each 1-SD increase corresponded to modestly longer LOS, higher risk of 30-day ED revisit and mortality, and worse DOOR scores, with minimal association with C. difficile infection (Figure 1). Concordance was strongly associated with better outcomes, including shorter LOS, fewer ED revisits, lower mortality, and lower DOOR scores. Mediation analyses (Figure 2) indicated that concordance explained about 11% of the SDI–LOS association and <5% of the associations with ED revisit, mortality, and DOOR. In secondary models (Figure 3), overuse was consistently associated with worse outcomes—longer LOS, higher mortality, and higher DOOR scores—independent of SDI. Underuse showed inverse associations with LOS and DOOR but only tiny, clinically negligible increases in ED revisit and mortality, patterns likely reflecting residual confounding and selection of lower-acuity patients. Conclusion: We found that social deprivation was associated with worse health outcomes, with antibiotic concordance serving as a partial pathway linking deprivation to harm. Stewardship efforts that improve concordance and curb overuse—particularly in socially deprived communities—may help reduce outcome disparities without encouraging under-treatment.

Background: Multiplex respiratory panels are commonly utilized in the clinical care of respiratory infections. This usage occurs despite their high cost and absence of impact on clinical decision making. Guidance from national societies such as the Society of Hospital Medicine and American Association of Family Practice suggest limiting use to immunocompromised hosts or targeted testing based on seasonal prevalence, however clinical practice often does not mirror these recommendations. Methods: We conducted a retrospective review of the ePlex repiratory panel, an automated polymerase chain reaction for detection and identification of multiple respiratory viral and bacterial nucleic acids, at University of Kentucky Healthcare during July 2024-June 2025. Test volumes were stratified by location and month. We assessed the frequency of insurance denials, and the estimated cost of unreimbursed testing. These results were then utilized to create a multi-pronged stewardship intervention. Results: A total of 15,320 tests were ordered, with 32.2% reporting at least one positive analyte, most commonly rhinovirus/enterovirus (25.5%) (Figure 1). Tests were most frequently ordered inpatient (7315 tests, 47.7%). Of the 3787 (24.7%) outpatient tests, urgent and primary care settings accounting for the largest propotion (46.5%). Insurance denials led to an unreimbursed cost of 1.78 million USD. Testing peaked in the winter months (1873 tests in December 2024), with a nadir of 935 tests in August 2024 (Figure 2). The intervention comprised three domains. First, the intervention was discussed and approval sought from key stakeholders including Lab formulary committee, inpatient and outpatient medical directors, Infectious Diseases, Laboratory services, and Pharmacy. Second, a comprehensive modification of the EMR including creation of nested order panels that led ordering users through clinical scenarios to determine if testing was indicated, selection of an appropriate use criteria if the test was ordered, and redirecting keywords to the order panel instead of the individual test order. Last, a patient/caregiver handout was created on supportive care for viral infections, and the lack of impact of multiplex testing in non-immunocompromised hosts. After the interventions went live in late-November 2025, test volume saw a significant decline with a 29% decline in November 2025, and a 73% decline in December 2025 (Figure 2). Conclusion: Our preliminary results show remarkable impact of a comprehensive diagnostic stewardship effort targeting appropriate test ordering of a multiplex viral respiratory panel. We plan to monitor long-term test usage, as well as impact on unreimbursed costs.

Background: Urinary tract infections (UTI) are common in the outpatient setting and a key focus of antimicrobial stewardship efforts. Inappropriate antibiotic prescribing persists, including low utilization of first-line agents. Limited research exists evaluating the drivers of variations in antibiotic prescribing for UTI. This analysis assessed associations between patient, clinician, and neighborhood factors and receipt of a first-line antibiotic for UTI. Methods: A cross-sectional analysis of adult (18 and over) urgent care visits from January 2023 to April 2025 in an integrated academic healthcare system was conducted, assessing antibiotic prescriptions for uncomplicated UTI visits. First-line antibiotics were defined as nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin according to IDSA clinical guidelines. Only visits associated with an antibiotic prescription were included in the analysis. Patient health status was assessed using the Charlson Comorbidity Index (CCI). Neighborhood factors were assessed using the Area Deprivation Index (ADI). Clustered logistic regression models were fit to assess factors associated with the likelihood of receiving first-line antibiotics. Results: A total of 13,092 UTI visits were included, of which 58% received first-line antibiotics. Patients were primarily White (73.7%), female (89.4%), and used commercial insurance (56.9%). The average age was 54.1 years, and the average CCI was 1.9. Age was associated with a lower likelihood of receiving first-line therapy; each additional year of age (<18) was associated with a 1% decrease in odds (Adjusted Odds Ratio (aOR) = 0.99, 95% CI = 0.98, 0.99). Similarly, each one-point increase in CCI decreased the likelihood of receiving first-line antibiotics by 4% (aOR = 0.96, 95% CI = 0.94, 0.97). Compared with men, women were less likely to receive first-line antibiotics (aOR=0.55, 95% CI=0.48, 0.62). Treatment by a physician assistant (PA) (aOR=0.91, 95%CI=0.83, 0.98) or a registered nurse (APRN) (aOR=0.66, 95%CI=0.60, 0.73) was associated with a reduced likelihood of first-line medication. Finally, being on Medicaid (aOR=0.82, 95% CI=0.71, 0.94) or Medicare (aOR=0.82, 95% CI=0.73, 0.91) was associated with a decreased likelihood of receiving first-line antibiotics. No statistically significant association was found between living in a more disadvantaged neighborhood, as measured by the ADI, and receiving first-line antibiotics. Discussion: Being older, female, in poorer health, treated by a PA or APRN, or having Medicare/Medicaid were associated with a lower likelihood of receiving first-line antibiotics for UTI. These findings provide critical information to understand variations in antibiotic prescribing for UTI. Further work is needed to identify the drivers of these differences to improve equity in stewardship.

Background and Objective: Antipseudomonal antibiotics are frequently initiated empirically in hospitalized patients with suspected pneumonia. However, de-escalation often remains suboptimal. Behavioral “nudge” interventions in microbiology reporting have shown potential to enhance antimicrobial stewardship. In June 2022, our institution implemented a revised microbiology comment in sputum culture result reporting emphasizing “commensal respiratory flora only: no MRSA or P. aeruginosa”. This study aimed to evaluate whether this reporting nudge increased de-escalation of antipseudomonal therapy within 24 hours of final respiratory culture results. Methods: We conducted a retrospective cohort study of adults (<18 years) admitted between December 1, 2021 - May 31, 2022 (pre-intervention) and July 1–December 31, 2022 (post-intervention) who had respiratory cultures obtained and were started on at least one antipseudomonal antibiotic within 48 hours of the culture being sent. Patients were excluded if cultures grew P. aeruginosa, if another infection required antipseudomonal coverage, if therapy was required due to allergies, or if they had neutropenic fever. The primary outcome was de-escalation, defined as discontinuation or narrowing of antipseudomonal therapy, within 24 hours of the finalized respiratory culture report. Secondary outcomes included duration of therapy, hospital length of stay, Clostridioides difficile infection within 30 days, and in-hospital mortality. Outcomes were compared in pre- and post-intervention cohorts. Results: Of 230 screened patients, 175 met the inclusion criteria (107 pre-intervention, 68 post-intervention). Approximately one-third of subjects had community-acquired pneumonia(34 in pre-intervention and 28 in post-intervention). Baseline characteristics suggested the pre-intervention cohort had higher severity of illness, with more ICU admissions (N =68 in pre-intervention and N=28 in post intervention) and more hospital-acquired (N= 21in pre and N=8 in post) or ventilator-associated pneumonia (N=7 in pre, N=2 in post). De-escalation within 24 hours occurred in (76) 71% of pre-intervention patients and (50) 73.5% post-intervention (p=0.72). Median duration of antibiotics after final culture result was 1 day (IQR, -1,3) in the pre-intervention group and 0 days (IQR, -2,3) in the post-intervention group (P=0.36). Median hospital length of stay was significantly longer in the pre-intervention group (IQR 13(6,20) vs 9 (5,16); p=0.03). Rates of C. difficile infection (<5%) and in-hospital mortality did not differ significantly between groups. Conclusion: Implementation of a microbiology nudge comment in respiratory culture result reporting did not significantly increase antipseudomonal antibiotic de-escalation. High rates of de-escalation were observed even prior to the intervention. Explanations for the finding may be that respiratory cultures are being sent unnecessarily and, therefore, they are not being used as data to act upon and/or anti-pseudomonal antibiotics are being started empirically unnecessarily, particularly in patients with CAP. The cohorts did differ in severity of illness, which may have impacted the results. These findings highlight the need for additional education regarding guideline-directed respiratory culture utilization and empiric antibiotic choices.

Background: Outbreaks of norovirus and other enteric diseases are common in long-term care facilities (LTCFs) such as nursing homes and assisted living facilities. During the COVID-19 pandemic, LTCFs enacted strict infection control measures which, combined with societal non-pharmaceutical interventions, may have limited the introduction of other infectious diseases, including norovirus, into these settings and reduced disease transmission temporarily. However, a newly predominant strain of norovirus was associated with abnormally high outbreak activity in the 2024-25 winter season. We describe changes to trends in norovirus outbreaks in LTCFs reported to the National Outbreak Reporting System (NORS) and CaliciNet, a strain surveillance platform, during the last decade. Methods: State and territorial health departments voluntarily report foodborne, waterborne, and other enteric outbreaks to the Centers for Disease Control (CDC) and Prevention through NORS. Public health laboratories report laboratory-confirmed norovirus outbreaks and genotypes to CDC through CaliciNet. Merged data from both systems were analyzed across four time periods: pre-pandemic, August 2015 – March 2020; pandemic, April 2020 – July 2021; post-pandemic, August 2021 – July 2024; and the 2024-25 season, August 2024 – July 2025. Both laboratory-confirmed (positive specimens from ≥2 case-patients or as defined by the reporting site) and suspected (<2 positive specimens) etiology outbreaks were included. Result: In total, 16,196 enteric LTCF outbreaks were reported to NORS and/or CaliciNet from August 2015 – July 2025, of which 12,905 (80%) outbreaks with 342,712 associated cases were attributed to norovirus. The average number of outbreaks reported over 12 months was 1,505 (7,022 total) during the pre-pandemic period, 256 (341 total) during the pandemic period, and 1,085 (3,256 total) during the post-pandemic period. The predominant genotype during these periods, GII.4 Sydney[P16], caused 42% of outbreaks with genotype data available. During the 2024-25 season, 2,286 LTCF norovirus outbreaks were reported (52% higher than the pre-pandemic period) and the predominant genotype (76%) was GII.17[P17]. Outbreak size (median [IQR]: 21 cases [11–35]) and duration (median [IQR]: 8 days [5–14]) were consistent across periods. Hospitalization rates were lowest during the pandemic period (1.8%) and highest during the 2024-25 season (3.2%). Conclusion: The low burden of LTCF norovirus outbreaks during the COVID-19 pandemic highlights the impact of non-pharmaceutical interventions in preventing outbreaks in this setting. The increased norovirus activity in the 2024-25 season associated with a new predominant strain suggests that more proactive laboratory testing in response to outbreaks is needed in this at-risk population to monitor trends in norovirus

Labor-managed firms, whether in the form of worker cooperatives, codetermination, or broad-based employee ownership, have recently prompted substantial public debate, to which political theorists have contributed with normative analyses that are seriously deficient insofar as they have neglected considerations of productive efficiency. I offer a normative view of labor-managed firms that leans squarely on efficiency considerations. I first argue that the value of productive efficiency is grounded not only on the interests of capital suppliers and society at large, but also on workers’ interest in avoiding domination by their bosses, and examine how efficiency may serve and set back this interest. I next argue that some variants of labor-managed firms can secure efficient production while protecting workers’ interest in nondomination more robustly than capital-controlled firms. Finally, I compare labor-managed firms to alternatives to achieve these aims, including self-employment, workplace regulation, unionization, and labor market policies to enhance workers’ exit options.

Background: Many Infectious Diseases (ID) fellowship programs have created antimicrobial stewardship (AS) scholarly tracks to guide burgeoning stewards. However, few programs have reported details of their AS curricula or career outcomes after track completion. We describe the major components of our AS track and the current AS-related faculty roles of prior participants. Methods: In 2015, our ID fellowship program, based at an academic medical center (AMC), formally created an AS track for second-year fellows (typically one fellow per year). The goal is to prepare fellows to become effective AS team members and potentially hold program leadership roles. We annually survey prior track participants regarding their current institution and roles. All current fellows are surveyed annually to evaluate AS-related rotations and conference series using a five-point Likert scale (1=Poor to 5=Excellent). Results: The track emphasizes three major components (Education, Mentorship, and AS Experiences) based on the SHEA White Paper “Guidance for the Knowledge and Skills Required for Antimicrobial Stewardship Leaders” (Cosgrove SE, ICHE 2014) (Figure 1). Early stewardship content education is provided through an annual conference series (“Summer Series”) and an experiential combined AS/Infection Control rotation for first-year fellows; both have demonstrated improved evaluation scores over the past five years (Figure 2). Since 2015, eight fellows have completed the second-year AS track; the majority currently practice at AMCs. Seven (88%; 7/8) currently report dedicated FTE support for AS activities and five (63%; 5/8) hold AS leadership positions as either Medical Director or Associate Medical Director (Table). Conclusion: During the first decade of our AS scholarly track, we developed a structured curriculum emphasizing acquisition of stewardship expertise, mentorship, and diverse experiential training. The majority of AS track fellow graduates continue in stewardship roles as faculty, including leadership positions, suggesting our longitudinal track may support early-career development in AS.

Background: The safety of midlines (MLs) versus peripherally inserted central catheters (PICCs) in the context of outpatient parenteral antimicrobial therapy (OPAT) is still debated. The Infectious Diseases Society of America guidelines currently offer a weak recommendation to consider MLs for antibiotic durations of <14 days. The purpose of this study was to quantify the ML complication rate compared to PICCs for OPAT. Methods: We performed a single-center, retrospective cohort study of MLs and PICCs placed by the bedside vascular access team for OPAT as recommended by the infectious diseases consult service at a 670-bed urban academic medical center. Between July 2019 and June 2022, 1351 catheters were placed in 1252 unique patients for OPAT. The primary exposure was the placement of a ML versus PICC, informed by selection guidelines from the Infusion Nurses Society. The primary outcome was any bloodstream infection (BSI) or superficial or deep venous thromboembolism (VTE) while the catheter was present. We estimated the hazard ratio (HR) of developing the outcome among MLs compared to PICCs using Cox proportional hazards models, accounting for multiple episodes of OPAT-related catheter placement over time in the same patient and adjusting for confounding by planned antibiotic duration of ≥14 days and the use of vancomycin. We tested whether planned antibiotic duration modified the association between catheter type and the outcome using an interaction term. Results Demographic and clinical characteristics are in Table 1. The ML complication rate was 6.1 per 1000 line-days (26 [3 BSI, 23 VTE] of 322 MLs) versus 1.2 per 1000 line-days for PICCs (40 [11 BSI, 30 VTE] of 1029 PICCs), with a higher complication rate for MLs (adjusted HR [aHR] 2.97, 95% confidence interval [CI] 1.32-6.70, p=0.01). Adjusted survival curves are given in Figure 1. The aHR was 0.97 (95% CI 0.30-3.11, p=0.96) among catheters with a planned antibiotic duration of ≤14 days and 4.11 (95% CI 2.08-8.16, p<0.01) for <14 days (p-interaction=0.03). Conclusion In this study of patients receiving OPAT, complications were uncommon but significantly more frequent for MLs than PICCs. This association appeared to differ by planned antibiotic durations of <14 days than ≤14 days. Our study calls into question the safety of MLs for OPAT, especially for prolonged durations of therapy.

Background: Mycobacterium chelonae and other non-tuberculous mycobacteria (NTM) isolated from ice/water dispensers have been implicated in healthcare outbreaks. We present the results of mitigation activities utilized to reduce M. chelonae from ice/water dispensers as part of an outbreak response. Methods: Interventions were performed in phases. Phase 1 involved ensuring compliance with the manufacturer’s ice/water dispenser cleaning protocol for 11 dispensers involved in the outbreak. Phase 2 compared monthly, bi-monthly, and quarterly cleaning outcomes of seven dispensers. Phase 3 evaluated point source controls on four dispensers in a test environment, two with a 0.005 µm microbial filter either solo (single stage) or in combination with a particle filter (two stage) and two with an ozone treatment system (each with a particle filter). In all phases, monthly environmental culturing for NTM was performed from four sources (water before the filter, water after the filter, ice and water from the spout) on each dispenser for four months. Additionally, swab samples of the waterspouts were collected in Phase 1. Several incoming water sources were also assessed for NTM. Identification of NTM from culture was performed by matrix-assisted laser desorption/ionization-time of flight mass spectrometry. Results: Phase 1 revealed one NTM positive sample from an ice/water dispenser in the first month with an increasing number of positive results each subsequent month with 40 /44 samples with NTM including 10 M. chelonae in month four. Phase 2 results did not show a significant difference in NTM results between groups by cleaning frequency. Phase 3 results continued to show positive NTM across all dispensers with the single stage microbial filter outperforming the other point source controls (Figure 1). The hospital incoming water results confirmed the presence of M. chelonae along with other species of NTM. Conclusions: Recovery of NTM including M. chelonae from the incoming water supply highlights the known risk from municipal water. Upon implementation of point source controls, the single stage filter had no NTM recovered from water immediately after the filter which may be beneficial. Despite robust and increased cleaning frequency, NTM was still recovered from all dispensers which suggests the presence of biofilm. Improved cleaning protocols are needed from ice/water dispenser manufacturers to address NTM biofilm issues in healthcare settings. Additionally, national guidance on management of NTM in hospital water systems to reduce risk to vulnerable patient populations is overdue.

Background: Clostridioides difficile is one of the most common healthcare associated infections. Due to diagnostic uncertainty, patients are often treated for colonization instead of infection. Colonization is not believed to be a direct precursor for a Clostridioides difficile infection (CDI) and does not require treatment. The aim of this study is to analyze factors associated with overtreatment for Clostridioides difficile colonization, and whether these factors contribute to recurrence. Methods: This study examined fully abstracted incident Clostridioides difficile cases, defined as the first positive stool test for persons at least one year of age residing in Davidson County, Tennessee from 2018–2022. Colonization was determined by negative enzyme immunoassay test combined with positive polymerase chain reaction test. Overtreatment was defined as receiving treatment for colonization. Recurrence was defined as a positive stool specimen between two to eight weeks of the last positive specimen. Overtreatment and recurrence were analyzed with two separate logistic regression models using SAS 9.4. Results: There were 1,097 patients examined. Of these patients, 61% were overtreated for colonization. Patients without comorbidities and with increasing age had lower odds of overtreatment (OR=0.6, 95% CI [0.4–0.9]; OR=0.7, 95% CI [0.6–0.8]). Patients with hospitalizations on the day of or in the six calendar days after the specimen collection or with diverticulitis or inflammatory bowel disease were significant for higher odds of overtreatment (OR=1.3, 95% CI [1.0–1.8]; OR=1.6, 95% CI [1.1–2.4]; OR=2.1, 95% CI [1.2–3.8]). There was no significance found for predicting overtreatment with other demographics or comorbidities (e.g., diabetes mellitus, chronic kidney disease, chronic pulmonary disease). Increasing age had higher odds of recurrence (OR=1.3, 95% CI [1.0–1.6]). No other factors associated with overtreatment were associated with recurrence. Conclusion: Overtreatment was common in this population. Hospitalization contributed to increased overtreatment of Clostridioides difficile colonization, and it is important to consider patient comorbidities that may present similarly to clinical CDI when considering treatment. Future studies should examine how overtreatment can affect other CDI outcomes and additional evaluation of general prevalence in the population, incidence of CDI, and mortality rates following overtreatment.

Background: Candida auris (C. auris) is an emerging multidrug-resistant fungal pathogen that continues to spread across the United States and remains classified by the Centers for Disease Control and Prevention as an urgent public health threat. Due to its ability to persist on surfaces and spread easily in healthcare settings, early detection and rapid infection control measures are critical to prevent outbreaks. Based on surveillance data, we implemented targeted C. auris screening in 2024 for patients transferred from outside healthcare facilities. After one year, we assessed adherence, positivity, and clinical infection cases to determine our program’s success and identify potential gaps in screening criteria. Methods: All eligible transfer patients received composite axilla/groin swabs on admission that were sent for external laboratory Polymerase Chain Reaction (PCR) testing. Demographic, clinical, and epidemiological factors, including transferring healthcare facility origin and co-colonizing multidrug-resistant organisms (MDROs), were evaluated alongside clinical C. auris infections identified outside of admission screening (e.g., urine, blood, pleural fluid). These were used to compare characteristics between colonized and infected patients and determine whether expanded screening criteria were warranted. All C. auris-positive patients were placed on transmission-based precautions with rapid notifications to unit leadership. Result: Over the first year (Sept 2024–Sept 2025), 1,725 of 1,937 eligible patients were screened (89.1%), with a positivity rate of 1.50% (26 colonized patients). Patient refusal and screening cancellations were infrequent (18 events; 0.06%). An additional 212 eligible patients (11%) were not screened due to operational factors, with no subsequent positive C. auris clinical cultures during hospitalization. Eight additional patients were diagnosed with C. auris infection through clinical cultures. These patients were ineligible for screening as they were not transfers, though most had frequent readmissions to and from outside healthcare facilities. Demographic and clinical characteristics of colonized and infected patients are summarized in Table 1. Conclusion: Our findings demonstrate that a targeted admission screening program for interfacility transfers identified colonized C. auris patients and enabled timely implementation of infection control measures. However, patients with significant outside healthcare exposure who are not interfacility transfers remain high-risk, indicating a gap in our current screening criteria.

Background: Residents living in post-acute and long-term care settings (PALTC) settings are particularly vulnerable to severe infections caused by common respiratory viruses, including COVID-19, influenza, and respiratory syncytial virus (RSV). The Perceived Vulnerability to Disease (PVD) scale has been used to understand general public perceptions of vulnerability to infectious diseases. We adapted the PVD for administration to PALTC residents and their care partners. Here, we describe the perceptions of infectious disease risk among Veterans and their care partners at a large Veterans Affairs (VA) PALTC setting, termed Community Living Centers (CLCs). Methods: From November 2024 to July 2025, we surveyed residents at a 152-bed CLC. Inclusion criteria were CLC residents aged > Results: Out of 81 eligible residents and LARs, 40% (N=32; 6 residents and 26 LARs) completed the survey. Regarding previous infections, 27 (84%), 9 (28%), and 0 (0%) respondents indicated that Veterans had tested positive for COVID-19, influenza, or RSV, respectively, during their CLC stay. No more than 9 (28%) perceived a moderate to high risk of infection with any of the pathogens during the next month (Figure 1). At least 12 (38%) of respondents agreed or strongly agreed with 6 of the 7 items for the Perceived Infectivity subscale of the PVD; at least 15 agreed or strongly agreed with 6 of 8 items for Germ Aversion (Figure 2). Conclusions: Participant responses to the Perceived Infectability and especially Germ Aversion indicated concerns with personal susceptibility to illness and general contamination. The perceived risk specifically to COVID-19, influenza, and RSV was comparatively lower, despite most Veterans having viral respiratory infections during their CLC stay. Although based on a small sample, our findings provide valuable insight about resident and LAR perspectives that can help inform and support infection prevention efforts in PALTC settings.

Background: Intravenous penicillin G is the preferred first-line agent for intrapartum Group B streptococcus prophylaxis; however, many pregnant patients carry unverified penicillin allergy labels. Although approximately 10% of the general population reports a penicillin allergy, only about 1% have a true allergy, and these inaccurate labels often lead to unnecessary use of broader-spectrum antibiotics, highlighting the need for improved allergy verification and de-labeling in obstetric care. Methods: A retrospective chart review was conducted from January 2022 to December 2024 evaluating documented penicillin allergies in pregnant patients who received care and delivered within a state-wide health system. Patients were excluded if they had a penicillin allergy documented during or after the encounter, or if the allergy was identified as an erroneous entry. A study-specific allergy risk assessment was used to stratify patients into no allergy, low risk, moderate-to-high risk, and severe risk categories, using a conservative approach as the true severity of historical reactions could not be definitively verified through retrospective chart review alone. Patients categorized as no allergy were considered eligible for de-labeling. Results: Of 303 birth encounters screened, 285 met inclusion criteria; ten patients with previously removed penicillin allergy labels were excluded from the primary outcome analysis. Among the remaining included encounters, 51 patients (18.5%) were identified as eligible for penicillin allergy de-labeling based on chart review alone. Eligibility was driven by documentation consistent with non-allergic reactions, including intolerance symptoms (5.8%), history of prior penicillin tolerance (10.5%), and reported familial allergy without personal reaction history (2.2%). Referral patterns for allergy evaluation were assessed to identify additional de-labeling opportunities. Only 12 patients were referred to an allergist during pregnancy; however, 11 of these patients underwent penicillin challenge testing and were successfully de-labeled. The high success rate among referred patients highlights frequent mislabeling of penicillin allergies and suggests substantial missed opportunities for broader de-labeling in the obstetric population. Conclusion: Nearly one in five pregnant patients (18.5%) with documented penicillin allergies were eligible for de-labeling based on chart review alone. Low referral rates for allergy evaluation also indicate significant opportunities to expand penicillin allergy testing in obstetric care, further improving antibiotic selection and antimicrobial stewardship.

Healthcare water management programs (WMPs) have historically emphasized the control of Legionella pneumophila, largely due to its established role in Legionnaires’ disease outbreaks. However, healthcare water systems harbor a wide range of opportunistic premise plumbing pathogens (OPPPs), including nontuberculous mycobacteria (NTM), Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, and Burkholderia cepacia complex. These organisms exhibit distinct ecological preferences and persistence mechanisms that vary by system type. In this study, we analyze microbiological testing data from more than 200,000 healthcare-associated water system samples collected since September 2019, comparing pathogen positivity across ice machines, general potable water, and cooling towers. Results demonstrate substantial variability in pathogen positivity by system type, with NTM showing markedly higher positivity in ice machines and potable water systems (relative to traditional indicator organisms). Legionella pneumophila positivity was highest in cooling towers but substantially lower in potable water. These findings indicate that uniform, organism-agnostic surveillance strategies are insufficient and that WMPs must be selectively designed based on system type, exposure route, and patient risk. Adopting site-specific, organism-selective monitoring frameworks may significantly improve infection prevention efforts in healthcare settings.