Infectious diseases fellowship programs for physicians seek to train the next generation of leaders in antimicrobial stewardship, but few published resources are available to guide educational experiences. As an adaptable tool for training programs, we created a list of entrustable professional activities and suggested tasks to achieve competency during fellowship.

Background: Effective infection prevention and control is integral to the delivery of safe patient care, and with ever increasing demands on their attention, systems to help navigate policy-based guidance can support infection preventionists (IPs) and their healthcare colleagues. Here we present the validation process and results for an internal infection control chatbot. Methods: Eleven frequently asked questions were selected to evaluate the performance of ChatUCM, an AI-powered chatbot. Each question was posed five times and response quality was scored by intent recognition, relevance, accuracy, completeness, and consistency. A category pass threshold was set at 75%. IP feedback was incorporated in a ChatUCM update and response quality was scored again. Reference document edits and real-time prompt modifications were made based on post-update scores. A final round of scoring was performed using similar validation metrics. Two IPs scored a subset of five out of the eleven frequently asked questions to assess interrater reliability. Six nursing managers were invited to ask ChatUCM any questions and score its responses by intent recognition, their ability to trust response accuracy, whether their question was fully answered, the achievement of intended goals, and ease of use. 29 questions were submitted. An IP reviewer also scored these ChatUCM responses as optimal, suboptimal/ no harm, and suboptimal/ possible harm. Results: The impact of the update on scores was variable. ChatUCM performed well on the same 7 out of 11 questions before and after validation round 1 (Fig. 1). After the final round of retraining, ChatUCM passed all categories with high interrater reliability for our frequently asked questions (Fig. 2). Response quality was less predictable outside of these eleven questions (Fig 3, Fig 4). To ensure its safe use, multiple safety checks were created, including disclaimer language, citation links, education, and a query report to facilitate audits. We encountered multiple surprises while validating ChatUCM. The first update resulted in significant improvements, such as the ability to digest data in table and flow diagram formats. It also saw category scores decrease for six questions, three of which had overall scores drop. ChatUCM struggled with accuracy for questions that required accounting for multiple clinical factors (ex: shingles guidance). Conclusions: These findings suggest that ChatUCM could substantially reduce IP workload by accurately answering questions contained in internal SOPs and policies. Additional development will be needed to improve reliability before the tool can function independently without human oversight, particularly when multiple clinical factors must be taken into account.

Background: Despite implementing standard infection prevention measures, our long-term care facility faced catastrophic outbreaks in units with cognitively impaired residents, where such interventions proved either ineffective or impractical due to staffing and resident-related challenges. Project Design: Confronted with constraints related to staff, residents, and resources common in long-term care facilities, we explored options for adjunctive measures to address these challenges, ultimately implementing dry hydrogen peroxide technology in these specialized areas. Outcomes and Lessons Learned: This intervention resulted in drastic reductions in microbial burden, the total number of outbreaks, outbreak attack rates, severity, and duration, while optimizing resident quality of life without placing additional strain on staff. Through this process, we learned that infection prevention interventions tailored to the characteristics of the population and facility yield maximum effectiveness.

Background: There is no gold standard approach to Clostridioides difficile (C. difficile) testing clinically. The National Healthcare Safety Network (NHSN) uses the last test in a series to determine if positive testing will be considered a healthcare associated infection (HAI) and there is concern that this may impact testing choice. Increasingly, healthcare facilities are considering 2-step testing algorithms, but limited data exists on clinical or surveillance motivations for algorithm choice. Methods: In October and November 2023, we distributed electronic surveys to Veterans Affairs Medical Center (VAMC) infection preventionists and infectious diseases physicians asking about current facility C. difficile testing practices, motivations for their current strategy, and considerations for change. Only one response was included per facility. Duplicate responses from the same facility were combined. Data were analyzed using Chi-squared tests. Results: Among 126 VAMCs, 72 (57%) completed the survey. The most common testing strategies were polymerase chain reaction (PCR) with reflex to toxin (n=31, 43%) and PCR with reflex to glutamate dehydrogenase (GDH)/toxin (n=20, 28%) when PCR is positive. Less common strategies included PCR alone (n=9, 13%), GDH/toxin with reflex to PCR when discordant (either GDH or toxin positive) (n=5, 7%), GDH/toxin alone (n=1, 1%), and other (n=6, 8%). Factors associated with testing strategy selection were avoidance of overdiagnosis (78%), to decrease rate of C. difficile HAIs (56%), and ease of interpretation (33%) (Figure 1). When comparing 2-step testing algorithms, avoiding overdiagnosis was a motivation for positive PCR with reflex to toxin or GDH/toxin (84%) as well as GDH/toxin with reflex to PCR (80%) (p=0.8). When compared to PCR with reflex to toxin or GDH/toxin, sites using GDH/toxin with reflex to PCR more frequently reported test turn-around-time (80% vs 14%, p≤0.001) and cost (60% vs 8%, p≤0.001) as motivating factors. Sites using PCR with reflex to toxin or GDH/toxin were more motivated by decreasing HAIs than GDH/toxin with reflex to PCR (63% vs 40%), although not statistically significant. Notably, 40% of facilities reported switching their testing strategy within 2 years of survey and 24% were actively considering a change. Conclusion: The most common testing strategy among VAMCs is a 2-step algorithm starting with PCR, then reflex to either toxin or GDH/toxin when PCR positive, driven by desire to avoid overdiagnosis and decrease HAI rates. It is unclear how this actually impacts rates or if this will change if facilities move to healthcare facility-onset, treated C. difficile infection metrics.

Background: The indications for the use of cardiac and endovascular implants have expanded worldwide. With increased utilization, there has been a proportional increase in implant-related complications, including infections. Epidemiological factors influencing patient outcomes in cardiac and endovascular implant infections (CEVII) are poorly characterized. We aimed to evaluate the epidemiology of CEVII and further, how healthcare utilization (HCU) patterns and the timing of infectious disease (ID) consultation influence hospital length of stay, a known surrogate of patient morbidity and quality of care. Methods: This retrospective study included patients admitted between 2010 and May 2025 with a CEVII encounter ICD-10 diagnosis of T82.7XXA, excluding deaths. For patients with multiple admissions, only the first encounter was analyzed. Descriptive statistics summarized patient characteristics, and we evaluated associations with the timing of ID consultation, HCU, and LOS. LOS modeling used generalized linear mixed models with a negative binomial distribution and log link, including categorical predictors and their interactions; significant interactions indicated effect modification. Model-adjusted mean LOS and 95% confidence intervals were obtained by exponentiating model coefficients. Analyses were performed in SAS 9.4, with p? Results: Among 763 patients with CEVII (1,168 admissions from 2013–May 2025), most were male (62%), White (76%), and Medicare beneficiaries (63%), with a median age of 61 years, median LOS of 8 days, and median Charlson Comorbidity Index (CCI) of 5.5. Early ID consult (<48 hrs.) occurred in 58.1% of cases, while 24% had no ID consult. Age and CCI were independent predictors of LOS, with no significant interaction with HCU. After adjustment, insurance type and the timing of ID consult significantly influenced LOS (p=0.0067), with late ID consults being associated with longer stays among Medicare and private insurance beneficiaries. Timing of ID consultation also interacted with admission period (pre-COVID, COVID, and post-COVID), with early ID consultationconsistently reducing LOS, while late consults resulted in the longest LOS, a difference amplified during the pandemic. Conclusion: Older patients with suspected CEVII who have high HCU and severe CCI experience longer LOS, underscoring the need for proactive care bundles to reduce excess stay and associated burden. Early ID consultation is critical, especially for Medicare and privately insured patients, where delays can lead to LOS penalties. Strengthening coordinated workflows to prevent delayed ID consultations during system strains, such as pandemics, can help avoid unnecessary prolonged hospitalizations and their impacts.

Purpose: Wastewater surveillance effectively monitors pathogens. This pilot study evaluated the feasibility and utility of hospital-level wastewater surveillance by integrating wastewater and electronic health record (EHR) data. Analyses focused on hospital-acquired infections (HAI) and temporal lags between wastewater and clinical detection. Methods: From August to December 2024, wastewater autosamplers operated across five hospital pavilions at Yale New Haven Hospital, collecting samples every five minutes during a 24-hour period three times per week. Samples were analyzed by dPCR for SARS-CoV-2, Influenza (A/B), and additional pathogens. Deidentified EHR data included admissions, diagnoses, and laboratory data. The primary focus was lab-confirmed HAI SARS-CoV-2 and Influenza. HAI was defined as infections diagnosed during hospitalization without evidence at admission. Clinical and wastewater data were used to calculate the proportion of positive samples, and correlation was assessed using Spearman’s rank correlation coefficient (rho). Correlations were evaluated for lagged associations across 1–3-week lags. A sensitivity analysis was conducted by including all SARS-CoV-2 encounters. Results: Among 33,579 patient encounters, 62 SARS-CoV-2 and 74 Influenza HAI encounters were identified. This corresponded to 97 and 148 tests for SARS-CoV-2 and Influenza, respectively. Of 187 wastewater samples collected 60 (31.1%) and 1 (0.5%) were positive for SARS-CoV-2 and Influenza respectively. Due to only a single detection of Influenza in the wastewater, correlation analysis was limited to SARS-CoV-2. A correlation test of the data found no statistically significant correlation between wastewater and clinical data when aligned temporally (rho: -0.21, p: 0.51). Lagged correlations between wastewater and clinical SARS-CoV-2 positivity were evaluated across 1–3-week temporal lags. These lagged correlations were not statistically significant, but rho increased in magnitude from a 1-week lag (rho: -0.04, p: 0.89) to a 3-weeks lag (rho: 0.46, p:0.21). The sensitivity analysis found no statistically significant correlation between wastewater and clinical positivity. Conclusions: Hospital-level wastewater surveillance shows potential as an early indicator of HAI SARS-CoV-2 infections, with exploratory trends suggesting a ~3-week lead time results in stronger associations between clinical and wastewater data. Although limited by small HAI sample sizes and a short wastewater sampling period, these findings support further evaluation in larger cohorts and highlights pathogen-specific limitations as observed for Influenza. Follow-up studies should employ longer wastewater sampling windows and further refine methods to account for community-associated SARS-CoV-2 contributions to hospital wastewater, an area of active investigation by our group.

Background: Community acquired pneumonia (CAP) is a common and frequently serious infection. Guidelines recommend empiric anti-MRSA and/or anti-pseudomonal therapy in patients with severe CAP who have previously grown those organisms in the last year or recently received intravenous antibiotics, as well as respiratory cultures for those on anti-MRSA and/or anti-pseudomonal antibiotics or with severe CAP. We previously showed overutilization of anti-MRSA and anti-pseudomonal antibiotics and underutilization of respiratory cultures in patients with CAP admitted to the ICU. Anti-MRSA antibiotics were readily de-escalated with negative MRSA nares PCR testing, but anti-pseudomonal therapy persisted even with respiratory culture data demonstrating absence of Pseudomonas. These findings were disseminated to ICU teams via departmental talks, bi-weekly in-person stewardship handshake, and an EMR nudge (for anti-pseudomonal prescribing). Here, we performed a timed reassessment of antibiotic use in this population following these educational initiatives while investigating additional factors that may influence empiric choice and de-escalation practices. Methods We performed an IRB approved single-center retrospective chart review including adult patients who were admitted to the ICU and received intravenous pneumonia-directed antibiotics within two calendar days of admission between January 1st, 2024 and August 31st, 2025. Patients were excluded if they were transferred from an acute care facility, were discharged or transitioned to comfort care within 48 hours of admission, had lung transplant or BMT, CF, PJP, lung abscess, empyema, suspicion for extra-pulmonary infection, any recent neutropenia (ANC<500), or were chronically ventilated. Data was collected from internal dashboards and manual electronic medical record review. Results Of the 658 encounters reviewed, 234 patient encounters were included in our primary analysis. 80% (187/234) and 77% (179/234) of patients received empiric anti-pseudomonal and anti-MRSA therapy, while only 28% (52/187) and 30% (54/179) had risk factors for Pseudomonas and MRSA, respectively. 43% (89/208) of patients with an indication for respiratory culture collection had one obtained within 48 hours of admission. Of the patients who grew only normal flora (with reported absence of MRSA and/or Pseudomonas) from their respiratory cultures, de-escalation of anti-pseudomonal antibiotics lagged behind that of anti-MRSA antibiotics (Figure 1A). Anti-MRSA de-escalation was associated with negative MRSA Nares PCR testing (Figure 1B). Conclusion Educational interventions were ineffective strategies to improve guideline concordant management of critically ill patients with CAP. Respiratory cultures remain infrequently utilized. Growth of normal flora on respiratory culture rarely results in de-escalation away from anti-pseudomonal therapy the way that negative MRSA nares testing does for anti-MRSA therapy.

Background: Since January 2025, critical structural and funding changes have altered the global healthcare landscape. To respond effectively, we performed a situation premortem. Premortem methods are commonly used within the field of implementation science to identify risk factors and early warning signs for failure of complex systems. Recognizing the systems-oriented nature of participant responses, we applied the socioecological model (SEM) to organize emergent themes. Methods In April 2025, a cross-sectional electronic premortem survey was distributed to IPC thought leaders. Participants were asked to imagine the year 2029 in which IPC research and practice had collapsed and to identify contributing factors, early warning signs, barriers, populations most affected, and missed opportunities for prevention or mitigation. Responses were analyzed using thematic content analysis. Themes were organized using the socioecological model to map findings across policy, community/professional, organizational, interpersonal, and individual levels. Results Nineteen of twenty-nine people agreed to participate (66.83% response rate) from the U.S., Australia, and Singapore. The majority (n = 13) were researchers with representation from clinical practice (n = 3), policy and regulation (n = 1), or in public health or professional capacity building (n = 2). Participants anticipated widespread consequences across all SEM levels (Figure 1). At the policy level, they described diminished IPC advocacy, global reversal of progress in infectious disease control, and increased economic burden. At the community and professional level, anticipated impacts included loss of public accountability, closure of training programs, reduced surveillance capacity, and fewer scholarly outputs to inform practice. Organizational consequences included inadequate funding of infection prevention/antimicrobial stewardship programs in healthcare facilities, workforce attrition, and increased legal risk. Interpersonally, participants anticipated inconsistent guidance and confusion, reduced support for frontline clinicians, decreased vaccine uptake, and diminished capacity to serve underserved populations. At the individual level, consequences included increased multidrug-resistant and healthcare-associated infections, fewer treatment options, lower vaccination rates, and increased morbidity and mortality among vulnerable, low-income, and immunocompromised individuals. Conclusion This premortem exercise highlights the potential impacts of a collapse of IPC research and practice. Participants anticipated cascading harms across multiple levels. These results identify areas for proactive, creative strategies tailored to specific socioecological domains of impact. Reliance on traditional federal funding models and the expectation for national data collection and reporting standards may be insufficient. The field must collaborate and develop alternative approaches to sustain IPC research, training, and practice to prevent negative downstream consequences and uphold professional values.

Precision medicine has a racial health disparities problem. Proponents of precision medicine claim it can combat health inequities, but precision medicine’s therapeutic products are exorbitantly expensive, creating a natural financial barrier to any systemic intervention. Defenders have suggested resolving this problem by shifting the focus of precision medicine research toward studying the social and environmental determinants of health. Where this proposed solution has been tried, however, it has led to the “methodological genomification” of health disparities. I’ll explain how this methodological genomification works and why it presents a real threat to research on the social and environmental determinants of health.

Background: Since 2014, the Centers for Disease Control and Prevention’s Core Elements of Hospital Antibiotic Stewardship Programs have evolved to incorporate multidisciplinary practices that optimize therapy and minimize antibiotic-associated harm. Infection preventionists (IPs) play a key role in stewardship efforts, especially education and reporting of event data; this study examined IP perceptions of inpatient stewardship programs. Methods: Members and non-members of the Association for Professionals in Infection Prevention (APIC) were invited to complete the quinquennial electronic survey between June and July 2025 through numerous emails, QR codes at the annual APIC conference, and social media campaigns. The survey assessed nine antimicrobial stewardship program (ASP) characteristics by practice setting (rural, suburban, urban), including structure, leadership, and educational resources. Descriptive statistics were used to summarize the data. Result: Responses were received from 1898 IPs in acute care hospitals. Most (n=1834, 96.7%) reported the presence of an ASP (Table 1). Only 5% (n=91) were unaware of program leadership, less often in rural settings (n=13, 2.6%) compared with 6.7% (n=54) in urban settings. Rural settings (n=238, 47.0%) were more likely to combine the antibiotic stewardship committee setting with other committees, such as an IP committee, compared to urban settings (n=194, 24.1%). Clinical pharmacists (n=797, 47.9%) and infectious diseases physicians (n=643, 38.6%) were most frequently identified as leaders, while IPs represented 1.3% of ASP leaders (n=21). Urban (n=570, 66.8%) and suburban (n=289, 56.6%) settings had greater access to infectious diseases physicians compared to rural settings (n=149, 28%). Over 80% (82.6%, n=1473) reported the use of up-to-date recommendations for infection management, and education was reported by 60.2% (n=1073), though 26.6% (n=475) were unsure if antibiotic prescribing education was specifically offered – findings consistent across settings. Multidisciplinary ASP rounding occurred in 66.6% (n=1188) of hospitals regardless of setting, with IPs attending in 27.1% (n=322) of institutions. IPs (n=119, 36.4%) were more likely to attend rounds in rural settings. Conclusion: ASPs are well-established in acute care settings, typically led by pharmacists and physicians. However, IPs are less frequently engaged in ASP activities, with limited participation in rounding and awareness of educational initiatives. An exception exists in rural settings, where IPs assume broader stewardship responsibilities. Expanding IP involvement and enhancing educational outreach across all care environments represent key opportunities to strengthen stewardship and improve patient outcomes.

Background: Environmental services (EVS) programs may choose dilutable (i.e., concentrate diluted manually or with an automated dispensing system) or ready-to-use (RTU) disinfectant products. Dilutable products are less expensive but have greater potential for incorrect use. Methods: We conducted a time and motion evaluation of EVS cleaning and disinfection practices before and after a facility-wide switch from dilutable to RTU quaternary ammonium disinfectant products. Observations were completed to determine the time required to complete tasks and the appropriateness of product use (e.g., correct product, contact time). Personnel were graded using a standardized compliance scale (17-20, highly compliant; 14-16 moderately compliant; 10-13, needs improvement). Results: We conducted 40 total hours of observations of 8 EVS personnel before and 10 after the product substitution. Mean compliance scores increased from 14.3 to 18.2 after the substitution. Noncompliance when dilutable products were used was most often due to incorrect use of products, including inappropriate mixing of disinfectant products (e.g., dilutable quaternary ammonium plus sodium hypochlorite) and inadequate contact time. During post-discharge and daily cleaning before the substitution, activities other than cleaning and disinfection accounted for 50% and 55% of total EVS personnel time, respectively (Figure), with similar time distribution after the substitution. Conclusions: Switching from dilutable to RTU disinfectants improved compliance with recommended cleaning and disinfection practices. EVS personnel spend a substantial proportion of their time doing activities other than cleaning and disinfection.

Background: With increasing utilization of oral antibiotics in serious infections, complex outpatient antimicrobial therapy (COpAT) programs are vital for improving patient safety and outcomes. We discuss the Michigan Medicine (MM) COpAT program, including processes, interventions, and evaluate its impact. Methods: Adult patients discharged from MM hospital between Jan-Oct 2025 were eligible for COpAT program enrollment if prescribed antibiotics for ≥14 days, including oral antibiotics requiring lab monitoring, long-acting lipoglycopeptides, or intravenous (IV) antibiotics administered at a hemodialysis center, subacute nursing facility, or home. Eligible diagnoses include osteomyelitis, prosthetic joint infection, septic joint, spinal hardware infection and infectious tenosynovitis. Established in October 2024, the COpAT program consists of an infectious diseases (ID) pharmacist with ID physician oversight. The pharmacist conducts a telephone-encounter within 2 business days of discharge to review antibiotic plan, lab monitoring, appropriate antibiotic administration, duration and adherence, and assess for adverse effects. The outpatient ID physician is notified of treatment concerns and lab monitoring results. Another telephone-encounter occurs 2 weeks post-discharge to re-evaluate antibiotic therapy. COpAT patient outcomes and process measures were compared to a historical cohort of patients discharged from MM on oral or IV antibiotics for an osteoarticular infection from May – August 2023. Chi-squared tests were used for categorical variables; the Mann-Whitney U test was used to compare median length of stay (LOS). Results: From January-October 2025, 163 patients with osteoarticular infections were enrolled in COpAT post-discharge. There were 124 patients in the historical cohort. Among COpAT patients, 79.8% (130/163) were discharged on oral antibiotics compared to 33.9% (42/124) in the historical cohort (p<0.0001, Figure 1). COpAT patients had a shorter median LOS of 6.1 days [IQR 4.2-8.7] versus 8.2 days [IQR 5.3-12.1, p<0.0001], and numerical reduction of 30-day readmission rate of 12% (19/158) versus 16.9% (22/132) in the historical cohort (p=0.258). In a subset of 85 patients enrolled from 1/1– 5/31/25, 96.5% had a COpAT telephone-encounter within 2 business days and 638 pharmacist interventions occurred with an average 7.4 interventions/patient (Figure 2). Conclusion: COpAT patients had significantly increased oral antibiotic utilization and shorter LOS, and numerically fewer readmissions compared to a historic cohort. The increase in oral and long-acting antibiotics, rapid post-discharge follow-up and multiple COpAT pharmacist interventions likely contributed to improved outcomes and safer transitions of care. COpAT programs should be instituted to improve patient outcomes and ensure safe use of oral and IV antibiotics in serious infections.

Background: Airborne infection isolation rooms (AIIRs) are a highly restricted environment in which patients’ physical and emotional care needs are intensified. In AIIRs, nurses spend the most time in close contact with patients, rendering the nurse-patient relationship particularly important. However, empirical research exploring nurse-patient relationships among patients isolated for infectious diseases remains limited. The Fundamentals of care (FOC) framework conceptualizes patients' physical and psychosocial needs and the nursing activities required to address them, positioning the nurse-patient relationship as the core dimension through which care is integrated and delivered within specific care contexts. This study aimed to explore nurse–patient relationships as experienced by patients in AIIRs and to interpret these experiences from the perspective of the FOC framework. Methods: Participants were adults aged 18 years or older who had been hospitalized for infectious diseases in AIIRs for at least three days. To ensure voluntary participation and authenticity of responses, patients who were not directly cared for by the researcher were recruited. Data were collected from 11 patients residing in AIIRs at a tertiary general hospital through semi-structured, one-on-one in-depth interviews conducted between July 6 and August 31, 2025. Interviews were audio-recorded and transcribed. Data were analyzed using thematic analysis following Braun and Clarke, employing a hybrid approach that integrated deductive coding based on pre-established FOC concepts with inductive coding derived from participants’ narratives. Results: The nurse–patient relationship experienced by patients in AIIRs was characterized by an overarching theme, a relationship of striving together along a long journey until returning to the world. Five main themes, comprising twelve subthemes, were identified: (1) feeling safe enough to entrust oneself, (2) experiencing continuous and attentive care, (3) experiencing prepared care, (4) recognizing the nurse as the one who understands me best, and (5) a relationship built together. Analysis revealed that patients in AIIRs experienced positive nurse–patient relationships through the development of trust and nurses’ attentive responses to their needs, which facilitated a shift from isolation-related anxiety to emotional stability. Furthermore, relationship development was described as a mutual process, with both nurses and patients actively engaged. Conclusion: This study suggests that nurse-patient relationship formation grounded in the FOC framework within AIIRs contributes to patients’ psychological stability and perceived recovery. The findings indicate the need for FOC-based nursing education, structured communication practices, and consideration of the AIIRs environment and institutional policies to support relationship-centered care in isolation settings.

Background: Diverticulitis is a common cause of emergency department (ED) visits for abdominal pain. Although recent guidelines recommend selective antibiotic use for low-risk cases, antibiotics remain commonly prescribed. Facility-level variation in prescribing practices has been underreported. Methods: We conducted a retrospective cohort study (2016–2023) using the Veterans Health Administration (VHA) Corporate Data Warehouse. We identified ED visits for a first episode of diverticulitis and excluded patients admitted within 48 hours. Low-risk cases were defined using International Classification Disease-10 codes for diverticulitis without perforation or abscess, Charlson Comorbidity Index <2, white blood cell (WBC) count <15 x 10^3 /?L, and C-reactive protein <14 mg/dL. We applied a multivariable mixed-effects logistic regression model with random facility intercepts to assess variation in antibiotic prescribing across VHA facilities, adjusting for patient demographics, WBC count, and facility complexity level. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated to assess the associations between patient-level variables and antibiotic prescription. Facility-level variation was quantified using the median odds ratio (MOR). Bootstrap resampling (2,000 iterations) was used to estimate 95% CIs for the MOR. Result: Among 4,214 patients (median age, 51 years; 84.6% male) from 72 facilities with ?10 eligible encounters, 176 (4.2%) did not receive antibiotics and 4,038 (95.8%) received antibiotics at ED discharge. Compared with patients who received antibiotics, those not receiving antibioitcs were less often White (72.1% vs. 76.7%). Abnormal WBC count was associated with antibiotic prescribing in the multivariable logistic regression model (adjusted OR 2.15 [95% CI: 1.13-4.08], p=0.019; Table). Facility-specific adjusted ORs ranged from 0.26 (95% CI: 0.14-0.48) to 1.50 (95% CI: 0.60-3.79), indicating heterogeneity in prescribing practices across the VHA system (Figure). The MOR for the facility-level variation in antibiotic prescribing was 1.70 (95% bootstrap CI: 1.00-2.22), suggesting a median 70% difference in the odds of receiving antibiotics between two otherwise identical patients treated at randomly selected facilities. In one significantly low-prescribing facility, review of 63 providers caring for 83 patients showed that among 13 providers who saw low-risk diverticulitis on more than three occasions, 10 prescribed antibiotics in all encounters, 2 in 50-99% of encounters, and 1 in 33%, suggesting provider-level variation. Conclusion: In this nationwide VHA cohort of low-risk diverticulitis, antibiotic prescribing varied across facilities after accounting for patient characteristics and facility complexity. The MOR indicates significant facility-level variation in antibiotic prescribing across facilities, highlighting opportunities for targeted antibiotic stewardship and implementation strategies to improve guideline-concordant care.

Deliberative democracy advocates argue that deliberation can strengthen democracy in part by reducing partisan hostility and affective polarization. Yet whether and why this holds remains relatively underexamined. This paper demonstrates that deliberation can reduce partisan animus by promoting engagement with out-partisan policy perspectives. This engagement builds cognitive empathy, increasing positive affect and tolerance toward out-partisans. Evidence is from an experiment in Honduras. Deliberators were randomly assigned to defend policies with which they agreed (own perspective) or disagreed (out-partisan perspective). Deliberation reduced affective polarization and out-partisan animus. These reductions were concentrated and more persistent in the out-partisan perspective group, while polarization increased modestly in the own-perspective group. The findings demonstrate that engagement with out-partisan policy viewpoints is an important causal mechanism driving deliberation’s impact while also highlighting the potential limits of deliberation and discussion in the absence of active engagement with out-group points of view.

Background: Penicillin allergies are common, reported in roughly 10% of the U.S. population, but fewer than 1% have a true IgE-mediated allergy. Penicillin allergy labels are associated with increased use of broad-spectrum antibiotics, higher healthcare costs, and the development of antimicrobial resistance. Antibiotic stewardship efforts have focused on identifying and de-labeling individuals without a true penicillin allergy. To date, most penicillin allergy de-labeling initiatives have been implemented in acute-care settings, where time constraints and clinical acuity may limit feasibility. Long-term care facilities represent a unique opportunity for penicillin allergy de-labeling, as residents often have prolonged stays and are less acutely ill. Previously, we found that 14% of residents admitted to the Veterans Affairs (VA) Community Living Center (CLC) in Vancouver, Washington had a documented allergy to a penicillin-class antibiotic. Here, we describe design and implementation of a penicillin allergy de-labeling program at a VA CLC and highlight opportunities for multidisciplinary collaboration. Methods: This antibiotic stewardship initiative was developed through collaboration between the VA Portland antimicrobial stewardship team and CLC providers, including physicians, nursing staff, and pharmacy. A standardized protocol was created to identify residents eligible for penicillin allergy evaluation and to outline steps for a direct oral challenge (Figure 1). At admission, CLC providers are instructed to identify residents with electronic health record (EHR) documentation of a penicillin class allergy and complete a structured allergy screening questionnaire. Residents with antibiotic intolerance alone (e.g., nausea and vomiting) receive education, and the penicillin allergy is removed from the EHR. Residents who require and agree to further evaluation are referred via electronic consult to the infectious diseases team, who verifies eligibility to undergo a direct oral challenge. CLC pharmacists review resident medications for any contraindications to performing a challenge, including receipt of medications that would reduce the histamine response. Eligible residents undergo a direct oral amoxicillin challenge with a single 500-mg dose and are monitored by nursing staff for 60 minutes. Patients without evidence of reaction receive education, and the penicillin allergy is removed from the EHR. Planned Evaluation: Planned outcome measures include completion of allergy screening, de-labeling based on chart review alone, eligibility for and completion of oral challenge, challenge outcome, and impact on subsequent antibiotic prescribing. Conclusion:This initiative describes a structured, reproducible framework for implementing penicillin allergy de-labeling in a VA post-acute care setting. The program has the potential to improve antibiotic selection and strengthen antimicrobial stewardship in skilled nursing facility (SNF) enviornments.

Background: The World Health Organization (WHO) designates Candida auris as a critical priority fungal pathogen due to its high multidrug resistance, transmissibility, and invasiveness, particularly in critically ill hosts, including the pediatric population. Here, we report the successful termination of a prolonged C. auris outbreak in a Pediatric Intensive Care Unit (PICU) using a multifaceted intervention strategy, including whole-genome sequencing (WGS) and unit-level clinical density reduction. Methods: This study was conducted in a 10-bed PICU at a 2,172-bed tertiary hospital in South Korea. Following an incidence surge in the second quarter of 2025, we implemented an intensive bundle in June 2025: (1) Surveillance: Point Prevalence Surveys (PPS), environmental cultures, and WGS to identify transmission dynamics; (2) Environmental Control: Terminal cleaning with 5,000 ppm sodium hypochlorite, daily cleaning frequency increased to three times daily with additional staffing, and real-time healthcare personnel (HCP) adherence monitoring; (3) Source Control: Active relocation of colonized patients to general wards to reduce PICU clinical density. Results: From January 2023 to June 2025, 28 C. auris isolates were identified from 27 patients. Urine was the primary source (n=20, 71.4%; 85.0% with indwelling urinary catheters), and four cases (14.3%) were candidemia. Incidence density peaked in June 2025 (13.89 per 1,000 patient-days) following a PPS that revealed a 28.6% positivity rate. Environmental cultures (monitor cables, infusion pumps) remained positive despite rigorous disinfection. WGS analysis identified all isolates as belonging to Clade I, consisting of two clusters with 100% resistance to fluconazole and amphotericin B. Genomic analysis further revealed that Cluster 2 was restricted to the PICU, confirming unit-specific reservoirs. To mitigate density, relocation was pursued for eight cases; five (62.5%) were transferred within five days of result reporting (range: -1 to 5 days). Despite delayed relocation in three cases (up to 76 days) due to clinical instability, no secondary transmissions occurred in general wards. Following these interventions, environmental cultures became negative, and the incidence rate dropped to zero through October 2025. Conclusions: C. auris can survive for prolonged periods on medical devices despite intensified protocols, including repeated 5,000 ppm terminal disinfection. Given this persistence, a multidisciplinary approach, coordination, and sustained adherence among HCP in the ICU are essential for successful outbreak control. Furthermore, active patient redistribution served as an effective unit-level source control strategy by reducing clinical density. The integration of genomic data was crucial for identifying unit-specific transmission patterns and validating the unit-targeted protocols.

Background Timely healthcare personnel (HCP) response during occupational exposure investigations is crucial for risk stratification, prophylaxis, and preventing secondary transmission. Non-response delays interventions, creates blind spots, and increases patient and workforce safety risks. Understanding pathogen-specific response patterns can inform targeted strategies to improve engagement and mitigate these risks. Objective To quantify pathogen-specific response and non-response rates among potentially exposed HCP and assess timeliness of engagement during occupational exposure investigations. Methods We conducted a retrospective review of occupational exposure investigations tracked in REDCap between November 2024 and October 2025 at an academic health system. Incidents involving Mycobacterium tuberculosis (TB), Neisseria meningitidis, Bordetella pertussis, and varicella-zoster virus (VZV) were included. HCP response was defined as reviewing exposure details and submitting required attestation online; non-response was failure to complete these steps. Data were extracted October 29, 2025. Descriptive statistics summarized response patterns. Comparisons and calculations of odds ratios (ORs) with 95% confidence intervals (CIs) were performed using chi-square analysis. Results Among 1,442 HCP notified of a potential occupational exposure, overall response was 90.5% (n=1,305) and non-response was 9.5% (n=137). Response within 5 days was 70% (n=1,003). Pathogen-specific response rates varied. HCP with a TB exposure (n=803) had 60% response within 5 days and 90% total response. Pertussis exposures (n=331) had 87% response within 5 days and 97.6% total response. VZV exposures (n=298) had the lowest engagement, with 77% response within 5 days and 83.6% total response. Meningitis exposures (n=10) demonstrated 90% response within 5 days and achieved 100% total response. When comparing response rates by pathogen, pertussis had significantly higher response rates compared to TB (OR 0.22, 95% CI 0.11–0.47, p < 0.001) and VZV (OR 7.95, 95% CI 3.70–17.08, p < 0.001). TB responses were significantly lower than VZV (OR 1.78, 95% CI 1.21–2.61, p = 0.004). Similar trends were observed for 5-day response rates. Conclusion Statistical comparisons underscore disproportionate engagement challenges concentrated in TB and VZV exposures. TB required significant additional outreach to achieve overall response, reflected in the gap between the 5-day response (60%) and final response (90%) values. VZV had the highest non-response rate (16.4%), though clinical impact may be mitigated by workforce immunity. HCP potentially exposed to pertussis and meningitis demonstrated outstanding response, 97.6% and 100% respectively, perhaps due to urgency for post-exposure prophylaxis when indicated. Pathogen-specific engagement strategies are warranted where delayed or absent responses pose safety risks.

Background: Nontuberculous mycobacteria (NTM) have caused serious infections following cardiothoracic surgery. In 2015, the first reports of NTM infections attributed to heater-cooler devices used during cardiopulmonary bypass (CPB) led to a prolonged international response. Surveillance and clinical management of these infections is challenging due to the long period (approximately 13–26 months) between exposure and disease presentation. Our objective was to describe the frequency and clinical outcomes of NTM infections following surgery with CPB among U.S. Medicare beneficiaries. Methods: We used Centers for Medicare & Medicaid Services claims data for Medicare fee-for-service beneficiaries. The study included adults who had (a) an inpatient claim with a procedure code for surgery requiring CPB between 2009–2021, and (b) an inpatient claim with a non-pulmonary NTM diagnosis code within two years after the index surgery. For beneficiaries with multiple surgeries in 2009–2021, only the first was included. Beneficiaries with an NTM diagnosis code on a claim in the year before the surgery were excluded. Demographic and clinical characteristics among cases and clinical outcomes in the two years after the index surgery were described. Results: Overall, 349 NTM case-patients with an index cardiothoracic surgery between 2009-2021 were identified. Cases had a median age of 70 years (interquartile range [IQR]: 65–77) (Table). The number of cases peaked in 2014 (n=40) and was lowest in 2018 (n=16) (Figure). The largest proportion of index surgeries were coronary artery bypass graft surgeries (45.0%), followed by cardiac valve surgeries (33.8%) and ventricular assist device surgeries (19.5%). The median time from index surgery to the first hospitalization with an NTM diagnosis code was 195 days (IQR: 75–416), and 26.9% of cases (n=94) had a diagnosis code for a serious infection (sepsis, endocarditis, or other bloodstream infection) at the time of the NTM diagnosis. During the two years after the index surgery, cases had a median of 4 inpatient hospitalizations and the median cumulative length of inpatient stays was 41 days (IQR: 18–77); 129 cases (37.0%) died, including 51 deaths among cases with a serious infection (54.3%). Conclusions: NTM infections following cardiothoracic surgery involving CPB continue to be identified despite heater-cooler device-related interventions. Although this claims-based analysis was unable to assess detailed clinical manifestations or cause of infection, the results suggest a need for continued attention to NTM prevention strategies in patients requiring CPB surgery to prevent these severe infections that are associated with multiple subsequent hospitalizations and high mortality.

A retrospective review of infectious diarrhea panel (IDP) utilization identified 62% of orders were non-adherent to clinical guidelines. Guideline-discordant orders were significantly less likely to (1) test positive for any target or (2) have impact on patient care. Improving IDP ordering for value-based healthcare is an important diagnostic stewardship intervention.