In this article, I explain how ideology in Russia’s war against Ukraine has been formulated within specific genres and discourses that are reminiscent of the carnivalesque. Mikhail Bakhtin’s concept of carnival has often been used to conceptualise forms of democratic resistance to authoritarianism. Yet alternative readings have always questioned this notion of carnival as liberation, and instead present the Bakhtinian carnival as a potential space and time of violent lawlessness and transgression. I use these contested readings to argue that ideology in Russia’s war is articulated and enacted through the carnivalesque, using forms of transgressive humor, grotesque imagery, and profane language. I use evidence from Russian social media channels, broadcast media, official discourse, and cultural production to support this Bakhtinian framing. The carnivalesque framing of wartime ideology enables Russia to mobilise and demobilise different parts of society simultaneously. It permits social distancing from the war for the Russian public, and enables the leadership to blur and obfuscate ideological tenets, while legitimising the creation of a space of exception in Ukraine, in which transgressive practices are normalised. In this way, carnival is a highly effective discursive mechanism for the transition during wartime to a more consolidated ideological regime in Russia.

Background: Handshake antimicrobial stewardship (AMS), characterized by regular, face-to-face interactions with antimicrobial prescribers with broad review of all active antimicrobials, is considered an AMS best practice. This approach fosters relationship building and increases opportunities for targeted education compared to traditional AMS activities. Reports of handshake AMS within surgical services are limited. We evaluated the impact of once-weekly handshake AMS rounds among general surgery teams in a 368-bed academic medical center. Methods: An infectious diseases physician and pharmacist conducted weekly rounds in general surgery offices with surgical residents, chief residents, advanced practice providers (APPs), medical students, and occasionally attending surgeons. All patients on antimicrobials and without an active ID consult were reviewed and recommendations with targeted education were provided. The number, type, and acceptance rate of recommendations were collected prospectively. Antimicrobial utilization within general surgery was reviewed pre- (1/1/2024-12/31/2024) and post-implementation (1/1/2025-12/31/2025) of handshake AMS rounds. Antimicrobial use data are presented as days of therapy (DOT)/1000 days present (DP). Results: From January 7, 2025, through January 6, 2026, 47 handshake AMS sessions were performed. Over this period, 215 recommendations were provided, and 173 recommendations were implemented, yielding a recommendation implementation rate of 80.5% and an average of 4.6 recommendations/session. The most common accepted recommendation types were duration modification (n=42, 24.3%), antibiotic stop (n=38, 22.0%), and de-escalation (n=33, 19.1%). Average DOT/1000 DP on general surgery teams for all agents dropped from 481.3 pre- to 462.8 post-implementation (3.8% relative reduction, p=0.578). Broad-spectrum antibiotic use dropped by 17.5%, from 369.2 pre- to 304.6 post-implementation (p=0.055). Anti-MRSA agent utilization remained stably low, with an average of 45.4 pre- vs 49.0 DOT/1000 DP post-implementation. The use of enteral metronidazole increased, from 4.9% pre- to 18.2% enteral/IV DOT post-implementation. Surgical providers consistently expressed appreciation for the practice-changing education provided during handshake AMS rounds and the resulting enhancements in antimicrobial decision-making and patient care. Conclusion: Targeted, once-weekly handshake AMS rounds with general surgery resulted in high-yield interventions with a high acceptance rate. Handshake AMS rounds could be an effective stewardship intervention in surgical practices and is doable despite the challenges of unpredictable operating room/provider schedules.

Background: Central line-associated bloodstream infections (CLABSIs) remain a challenge in pediatric care, particularly among medically complex patients requiring prolonged catheterization. Critically ill and immuno-compromised patients maintain high CLABSI rates despite robust efforts to reduce infections. A multifaceted approach to prevention is required, including evidence-based practice standards, competency evaluation, and bundle reliability. Objective: To establish adherence to evidence-based practice standards and evaluate competency. Design/Methods: A structured, multi-unit competency module was developed, emphasizing five core domains of central venous catheter (CVC) care including: sterile dressing changes, timely and aseptic needleless connector changes, standardized use of CVC coverings and securement devices, evidence-based lab-drawing procedures, and skin and environmental hygiene practices; including bathing, room cleanliness and linen management. Staff completed return demonstrations and direct observation audits from March 2024 to March 2025. Units were determined based on NHSN Targeted Assessment Prevention (TAP) report targeting locations with the greatest need. Baseline (January 2023-Febuary 2024) and post-implementation (April 2025 – December 2025) CLABSI rates per 1000 catheter days were measured. Concurrent to the competency, additional interventions included: web-based learning on CVC dressing, chlorhexidine treatment campaign and enhanced visual displays, development and use of high-risk CLABSI reports, and creation of an infection prevention committee in oncology. Results: Three units were identified for the intervention from March 2024 to March 2025, including our medical-surgical intensive care unit (ICU), Hematopoietic Stem Cell Transplant Unit (HSCT), and hematology/oncology. During demonstration, corrections were made on practices, resulting in improved adherence to key CVC maintenance practices, with the most significant improvements seen in dressing and needleless connector change technique and lab-drawing asepsis. From observation, skin and environmental hygiene practices also improved, supporting a need for a comprehensive approach to CLABSI prevention. The overall CLABSI rate for these units decreased from 1.1 pre-intervention to 0.55 post intervention (excluding the intervention period). Most notably, the HSCT unit decreased their CLABSI rate by 100% with zero CLABSIs since intervention resulting in a shift in the mean, and the MSICU saw a 60% reduction.Conclusions: A back-to-basics CLABSI competency and other prevention interventions effectively reinforced essential CVC care practices and improved standardization across inpatient units. Re-establishing core competencies paired with direct observation and environmental hygiene reinforcement, supports sustained reductions in CLABSI risk and strengthens a culture of line safety. Continued monitoring and annual competency refreshers are recommended to maintain practice reliability. Keywords: CLABSI, pediatric oncology, pediatric intensive care, quality improvement, infection prevention

Background: Microbiome restoration through fecal microbiota transplantation (FMT) is a promising decolonization strategy that reduces multidrug-resistant organism (MDRO) colonization and infection. However, the strains mediating MDRO decolonization remain poorly defined, and long-term follow-up (LTF) data after FMT for MDRO decolonization are limited. We enrolled participants from a completed randomized trial of FMT for MDRO decolonization (PREMIX, NCT02922816) into an LTF study to characterize long-term engraftment dynamics of donor-derived anaerobic taxa and their association with sustained MDRO decolonization. Methods: Participants provided stool samples every six months for up to five years following completion of the trial. Samples underwent selective culturing for MDROs using chromogenic agars, with organism identification and susceptibility confirmation by MALDI-TOF and Vitek2. MDRO isolates underwent whole-genome sequencing (WGS), and stool samples underwent metagenomic sequencing. To determine similarity between baseline and LTF MDROs, pairwise comparison of baseline and LTF MDRO isolates was performed with a unique strain defined as < 99.5% average nucleotide identify difference (ANI) to other strains. To determine engraftment of donor derived anaerobic taxa construction of metagenome-assembled genomes (MAG) from donor and participants samples was performed. Donor MAGs detected at <50% breadth in LTF metagenome samples were compared to corresponding species-level MAGs from participant LTF samples, with unique MAGs defined as <99.5% ANI like strains above Results Six PREMIX participants were enrolled to the LTF study, five of whom received FMT and one control. 80% (4/5) of FMT treated patients have remained decolonized (culture negative) while 0% (0/1) of control patients have remained decolonized at most recent follow up (median[IQR] 3.6 [3.4,4.0] years). The single FMT-treated participant with MDRO detection in LTF samples had evidence of a new acquisition compared to the baseline MDRO, whereas the MDRO detected in the control participant was identical to the baseline strain based on ANI cut offs. Among FMT-treated participants, metagenomic analysis demonstrated persistent detection of donor-derived anaerobic strains at <50% breadth, with high ANI between donor MAGs and participant LTF MAGs for multiple key taxa, including Acetatifactor sp., Akkermansia muciniphila, Alistipes putredinis, Barnesiella intestinihominis, Eubacterium siraeum, Mesosutterella massiliensis, Odoribacter splanchnicus, and Phascolarctobacterium faecium, consistent with long-term engraftment (Figure 1). No donor-derived MAGs were detected in control participants at <99.5% ANI. Conclusions: FMT was associated with long-term durable decolonization potentially mediated by the engraftment and persistence of key donor derived anaerobic strains. Our findings of persistence of discrete taxa highlights the potential for developing rationally constructed strain-based microbiome therapeutics for decolonization and infection prevention.

Background: Our prior research demonstrated that Escherichia coli antimicrobial resistance varies geographically at a neighborhood level and antibiotic resistance risk is associated with patient demographics. This study aimed to examine whether antimicrobial resistance exhibits spatial dependence beyond individual-level risk factors. Methods: We performed retrospective geospatial analyses of patient characteristics and 2019-2024 E. coli antibiotic susceptibilities from Marshfield Clinic. Patients who had cultures positive for E. coli with susceptibility data were included with their first unique isolate per year (N = 36,043). All covariates were encoded as binary (0/1) indicators, including sex (female), farm residence, public insurance coverage, age under 18 years, age 65 years or older, White race, and antibiotic exposure within the prior 90 days. Outcomes included binary indicators of E. coli susceptibility vs non-susceptibility (intermediate or resistant) to ciprofloxacin (CIP), trimethoprim/sulfamethoxazole (SXT), cefazolin (CFZ), ceftriaxone (CRO), nitrofurantoin (FM), and tetracycline (TE). We first estimated standard logistic regression (binomial logit) models with antimicrobial non-susceptibility as the dependent variable and the full set of covariates as predictors. We then estimated spatial autoregressive probit models using Bayesian Markov Chain Monte Carlo methods (SAR-probit), which explicitly incorporates spatial dependence through a spatially lagged latent propensity. Spatial relationships were encoded using a K-Nearest-Neighbors-based spatial weights matrix constructed from point coordinates, with the neighborhood size (k = 25) selected based on a preceding calibration procedure. We compared non-spatial and spatial models to assess whether spatial clustering in antimicrobial resistance persists after accounting for demographic and exposure-related covariates. Results: Consistent with our prior results, logistic regression showed many patient demographics as significant independent predictors, with all variables significantly associated with ciprofloxacin resistance (p < 0.05) and some variation by variable with each of the other antibiotics. The spatial autoregressive parameter results indicated risk of E. coli non-susceptibility is influenced by nearby neighborhood non-susceptibility for all analyzed antimicrobials: CIP (rho = 0.633, p < 0.001), SXT (rho = 0.596, p < 0.001), CFZ (rho = 0.603, p < 0.001), CRO (rho = 0.639, p < 0.001), FM (rho = 0.708, p < 0.001), and TE (rho = 0.580, p < 0.001). Conclusions: An individual’s risk for an antibiotic-resistant E. coli infection is affected by their neighbors’ antibiotic resistance. This statistically significant geographic pattern in antibiotic resistance remains while accounting for known patient-level risk factors for antibiotic resistance. The results support patient-level strategies that are informed by community antibiotic resistance surveillance.

Background: In adult hospitals, daily disinfection using a sporicidal agent in patient rooms has resulted in sustained reduction in Clostridioides difficile infection (CDI) rates. No studies have evaluated the impact of this intervention in a pediatric setting. Objectives: We sought to evaluate the impact of daily sporicidal disinfection of high-touch surfaces in rooms of hospitalized pediatric oncology and stem cell transplant (SCT) patients on the incidence density of hospital-onset CDI, and to identify strategies to optimize reliability of disinfection by clinical staff. Methods: We introduced a quality improvement intervention in which nurses disinfected 6 high-touch surfaces in patient rooms with bleach wipes twice daily. PDSA cycles were used to improve reliability of disinfection. We used a controlled interrupted time-series analysis with a non-equivalent control group (pediatric ward housing solid organ transplant recipients in which no sporicidal disinfection was introduced) and also tracked a non-equivalent dependent variable (catheter-associated UTI rate) expected to be unaffected by the intervention. Autocorrelated segmented regression models were used to compare CDI rates in each period (pre: June 2022-January 2024, post: February 2024-November 2025), adjusting for total antibiotic days of therapy. Other potential confounders (including reliability of hand hygiene, personal protective equipment, and room cleaning) were also monitored. Results: Sociodemographic and clinical characteristics among encounters on intervention units were similar pre- and post-intervention. The overall CDI rate on the oncology and SCT units was 20.5 per 10,000 patient days with no difference pre- vs post-intervention (19.0 vs. 21.9, p=0.46). The average monthly reliability of sporicidal disinfection across the post-intervention period was 56%. The model-estimated monthly trend in CDI rate on the intervention units decreased from 1.00 (pre) to 0.32 (post) (p=0.24) and showed a greater but non-significant month-over-month decline in trend compared with the control unit (β=-0.28, p=0.74). Hand hygiene and other confounders were similar across periods. There was no change in control unit CDI trend pre- vs post-intervention (p=0.48) (Figure 1). The CAUTI rate did not change between periods on intervention or control units. Conclusions: Introduction of daily sporicidal disinfection of high-touch surfaces by nurses in the rooms of pediatric oncology and stem cell transplant patients was followed by a modest (but not statistically significant) decrease in monthly trend of hospital-onset CDI rate, despite only moderate reliability of disinfection. Our results suggest a potential benefit to including sporicidal disinfection as a routine component of CDI prevention in a pediatric hospital.

Background: Within-hospital transmission has been reported with carbapenem-resistant Enterobacterales (CRE) infections. At our medical center, much of the CRE submitted for carbapenemase surveillance is non-carbapenemase producing (non-CP-CRE). We explored risk factors for CP-CRE vs non-CP-CRE infections in a cohort in our center in which both CP-CRE and CRE overall are rare to explore the hypothesis that horizontal transmission is more likely with CP-CRE. Methods: All patients with meropenem-resistant Enterobacterales isolated at MUSC March 2022 through February 2025 that were submitted to the state public health lab for modified carbapenem inactivation method (mCIM) testing and reflex metallobetalactamase gene PCR (CARBA-R, Cepheid) were included. Patients with positive mCIM were defined as carbapenemase-producing CRE (CP-CRE). A subset of CP-CRE patients from January 2024-February 2025 was compared to patients with non-carbapenemase-producing CRE over the same period and underwent chart review regarding antimicrobial exposures, past infection with other MDROs, past healthcare facility exposure, and other clinical features. Results: Over the study period 170 total CRE isolates were forwarded, of which 83 (48%) were confirmed CP-CRE, of which KPC (68, 82%) and NDM (15, 18%), and oxa-48-like (1, 1%) were the mechanisms detected. Klebsiella pneumoniae (54/83, 65%) and Enterobacter spp. (35/87, 40%) were the most prevalent CP-CRE and non-CP-CRE species, respectively. From January 2024 – February 2025, 35 CP-CRE and 31 non-CP-CRE-infected patients were reviewed. CP-CRE was associated with resistance to several non-beta-lactam antibiotics whereas non-CP-CRE was significantly associated with prior exposure to carbapenem-class antibiotics in the prior 90 days (23% vs 3%, P = 0.021). No other significant differences in the two groups were noted apart from prior MRSA infection and solid organ transplant status associated with non-CP-CRE (Table). Conclusion: CP-CRE is associated with more significant multi-class resistance and much less associated than non-CP-CRE with prior carbapenem exposure, suggesting that horizontal transmission may play a more important role in CP-CRE infections whereas in-patient evolution of CRE may play a larger role in non-CP-CRE infections.

Background Bacterial resistance to frequently used antimicrobial therapies is a significant threat to human health. Chlorhexidine digluconate (CHG) is a topical antiseptic used to reduce healthcare-associated infections, including those caused by multidrug-resistant organisms. There is concern that exposure to CHG may lead to elevated bacterial CHG minimum inhibitory concentrations (MICs) in healthcare environments where the antiseptic is used. We investigated whether skin bacteria of CHG-exposed patients had elevated CHG MICs compared to patients without CHG exposure. Additionally, we evaluated whether bacteria isolated from environmental surfaces of CHG-exposed patients and from surfaces with detectable concentrations of CHG had higher CHG MICs compared to bacteria isolated from room surfaces without CHG exposure or from surfaces without detectable CHG. Methods We recruited a prospective observational cohort including two patient groups: 15 patients without CHG exposure during hospitalization, and 15 patients with daily CHG bathing for ?14 days prior to enrollment. Informed consent was obtained, and clinical data were recorded. Skin and environmental swab samples were collected using E-swabs and sponge sticks respectively and cultivated on non-selective media (Figure 1). A subset of isolates underwent CHG and antibiotic MIC determination by microbroth dilution. Swab samples of the same locations were collected using pre-moistened sterile water swabs and processed via colorimetric assay. Data were analyzed using multilevel models. Results No significant clinical differences between groups were noted, including in antimicrobial exposure or infection history. 360 unique bacterial isolates were identified, with Staphylococcus epidermidis and Staphylococcus hominis being the most common organisms isolated from all skin and environmental sites (Table 1). CHG MICs were not significantly different across all organisms detected at all sites in exposed versus non-exposed groups (p=0.4) (Table 2). No residual CHG was found on skin or environmental surfaces of the CHG non-exposed group. Residual CHG in the exposed group was most frequently detected on the anterior chest (n=13/15) and bed handle (n=8/15), and levels of residual CHG on body sites were significantly elevated compared to environmental sites (p=<0.0001). Bacteria found where residual CHG was detected on both skin and environmental sites did not have significantly elevated CHG MICs (p=0.21). Conclusion We found no evidence that CHG exposure correlates with elevated CHG MICs of skin or environmental bacteria, suggesting routine CHG use to prevent infections does not contribute to resistance. This study is the first to correlate bacterial CHG MICs with residual environmental CHG, and to perform colorimetric CHG testing on environmental surfaces.

Background: National guidelines recommend that anyone diagnosed with a sexually transmitted infection (STI) be tested for other STIs. However, in the majority of cases, appropriate STI co-testing is not performed. Additionally, STI diagnosis is often a missed opportunity for referral for HIV pre-exposure prophylaxis (PrEP). Order sets can be an effective tool within electronic medical records (EMR) to standardize diagnostic and therapeutic pathways. We sought to improve STI co-testing, PrEP referrals, and antimicrobial management through the implementation of a diagnostic and treatment order set within the Durham VA Health Care System (DVAHCS). Methods: An STI order set prompting co-testing was implemented in September of 2024 across DVAHCS. STI co-testing rates were analyzed one year pre- and post-implementation. Interrupted time series (ITS) analysis was performed using Gaussian regression to evaluate the effect of order set implementation for both co-testing of gonorrhea, chlamydia and syphilis (GCS) and additional cotesting for HIV (total STI). New starts and overall administration of HIV PrEP and order set utilization for therapeutics were analyzed using incidence rate ratios (IRRs) comparing incidence rates pre- and post-implementation. Result: The GCS cotesting IRR was 0.991 (p p p p p p p p p = 0.582). (Figure 3) The treatment order set was used on average 24.6% of the time after implementation. (Figure 4) Conclusion: The implementation of a STI co-testing order set did not change the rate of co-testing for chlamydia, gonorrhea, syphilis and HIV. An accompanying treatment order set was used to a significant degree, although in a minority of cases. There was no significant change in the initiation of PrEP after implementation of the order set as compared to prior. Our study was limited by small numbers of incident STI diagnoses. Further research is warranted to understand the optimal ways towards increasing recommended testing patterns and how tools within EMRs can assist with this goal.

This article examines a fundamental transformation in thirteenth-century theory of science by tracing the shifting role of the subiectum scientiae in scholastic theology. While Aristotelian epistemics defined a science through a unitary subject conceived as a logical genus, medieval debates—especially within the Parisian university context—revealed increasing tensions when applying this framework to theology. Focusing on key figures such as Robert Kilwardby, Thomas Aquinas, and Giles of Rome, the article reconstructs an epistemological turn whereby the subject of science was progressively reinterpreted in relation to the intellect and its objects. Kilwardby’s essentialist redefinition of the subject as a unified nature laid the groundwork for this development. Aquinas advanced it further by integrating the notion of obiectum and emphasizing the role of the intellect, introducing a dual account in which both subject and formal object contribute to the unity of a science. The decisive shift occurs in Giles of Rome, who effectively collapses the distinction by identifying the subject with the principal object of cognition, thereby centering epistemology on the relation between intellect and object. This reorientation foregrounded the limits of human cognition and intensified debates about the scientific status of theology, particularly in contrast to divine and beatific knowledge. The article argues that these developments culminate in an emergent notion of “subjective science,” wherein the identity and validity of scientific knowledge become inseparable from the capacities of the knowing subject. This medieval trajectory, far from being anachronistic, offers a historically grounded account of the epistemic conditions that anticipate later conceptions of subjectivity.

Background: Over-utilization and inappropriate interpretation of urinalyses and urine dipsticks drives unnecessary urine cultures, leading to unnecessary treatment of asymptomatic bacteriuria (ASB), avoidable antibiotic associated adverse drug effects, and risk of antimicrobial resistance. The urinalysis with reflex order set (UA w/ reflex) is a stewardship intervention to reduce unnecessary cultures. Providers can elect to bypass the reflex criteria by selecting specific clinical indications (e.g., pregnancy) to culture urine regardless of urinalysis results. We aimed to assess the appropriateness of provider bypass selection and the effect on appropriate antibiotic prescribing for urinary tract infections (UTIs). Methods: From a dataset of adult outpatient encounters in which the UA w/ reflex order set was used at Vanderbilt University Medical Center (VUMC) between June 1, 2022 and June 30, 2024, 120 patients were randomly selected for review as part of an ongoing study. Of those, patients <16 years of age, hospitalized within 2 days of UA, with delay of UA acquisition, or with incomplete encounter documentation were excluded (N=20). Patient and provider demographics, patient symptoms, physical exam findings, urine diagnostic testing, and antibiotics prescribed were extracted from the electronic medical record (EMR) and via manual chart review and analyzed. Results: Of the 100 included patients, the average age was 48.9 years and 64% were female. Of the 32 (32%) who received antibiotics, 24 (75%) had a possible UTI or indication for treatment of ASB (“appropriate”), and 8 (25%) had nonspecific or no symptoms (“inappropriate”). Among 13 patient encounters which inappropriately bypassed the reflex criteria, 1 (14%) received “inappropriate” antibiotics compared to 2 (33%) who received “appropriate” antibiotics (p = 0.559), see Table 1. Among those where the culture reflexed per protocol (n = 59), 45 had non-specific or no symptoms (76%) and 41 (91%) did not receive unnecessary antibiotics (p<0.0001). This difference was not seen in bypass appropriate or bypass inappropriate groups (p=1.00 and p=0.559 respectively), see Table 1. Conclusions: In this preliminary analysis, we observed high (~1/3) rates of inaccurate selection of bypass criteria; however, this was not associated with increased inappropriate antibiotic prescribing, which may have been due to the small sample size. Antibiotic prescribing was lowest when the reflex order was used appropriately. Additionally, high rates of orders without UTI symptoms were noted, suggesting potential diagnostic mis-stewardship. Behavioral drivers and clinical triggers for ordering UA w/ reflex need to be better understood to target reducing inappropriate testing.

Background: Inappropriate urine culture ordering among catheterized patients can result in overdiagnosis of catheter-associated urinary tract infections (CAUTI) and unnecessary antibiotic exposure. We sought to reduce inappropriate urine culture ordering at our 167 bed acute care hospital with targeted diagnostic stewardship educational initiatives to hospitalist, emergency room, and intensive care unit providers (ICU). Objective: Estimate the impact of educational workshops on appropriate urinary ordering practices among inpatient providers at a single small acute care hospital. Methods: Retrospective observational cohort study of all catheterized patients receiving a urinalysis with reflex to culture from March 2023-April 2025. Workshops were held during different months tailored to provider groups, and attendance was recorded. Categorization of order indications and appropriateness were assessed retrospectively by a study team member applying established algorithms (i.e., IDSA guidelines with minor modifications). Patient clinical and encounter data were extracted from the electronic health record. Indications and appropriateness of orders were compared between provider groups and by provider attendance at a workshop by univariate and multivariate analysis. Results: Of 139 urinalyses with reflex to culture orders, 63 (45%) were ordered by Hospitalists, 40 (29%) by critical care providers, and 36 (26%) by other provider groups; 81 (59.6%) were inappropriate, without differences in appropriateness by provider group (p=0.10). Frequency of ordering decreased over time (7.2/month prior to last workshop vs. 4.2/month after, Figure); however, the proportion categorized as inappropriate appeared stable over time (Figure). Appropriate orders were mostly for UTI symptoms without fever (14, 25.5%), with fever (10,18.2%), or sepsis (16, 29.1%). Provider workshop attendance was as frequent among appropriate orders as inappropriate (25/55, 46% vs. 26/81, 32%, p=0.12). There were no significant differences in catheter duration, comorbidity score, and various primary discharge diagnosis by order appropriateness. Conclusion: Over two years, a majority of urinalysis with reflex to culture orders among catheterized patients were inappropriate. While diagnostic stewardship workshop attendance did not appear to impact likelihood of an order to be appropriate, we did observe an overall decrease in orders suggesting educational efforts may have influenced ordering behavior.

Background: Effective implementation of infection prevention and control (IPC) reduces the risk of healthcare-associated infections (HAIs), thereby protecting patients and healthcare workers. Tanzania has experienced ongoing outbreaks demonstrating a need for stronger IPC. Amref Health Tanzania, in collaboration with the Ministry of Health and U.S. Centers for Disease Control and Prevention, implemented a multimodal project in Kigoma, a high HAI-risk region, aimed at improving IPC practices in 20 healthcare facilities (HCF). It involved activating Quality Improvement Teams (QIT), supportive supervisions and mentorships, quarterly standardized assessments using the national Standard Based Management and Recognition (SBMR) tool, and virtual and in-person trainings. We evaluated progress and effectiveness of the project. Methods: We conducted a mixed methods evaluation of the project in March 2024. Ten HCFs were selected purposively to have variation on location, IPC performance, and level and convenience sampling was used to select staff. A comparative cross-sectional design was utilized to collect data through focus group discussions (FGDs), key informant interviews (KIIs), and quantitative knowledge assessments and practice observations. A comparison of SBMR results at baseline (September 2021) and endline (October 2023) was completed to assess effectiveness of the project. Quantitative data were analyzed using STATA 14 software and thematic analysis was conducted for qualitative data. Results: Ten FGDs, 8 KIIs, 150 knowledge assessments, and 6-11 observations per HCF were conducted. The SBMR baseline to endline comparison showed IPC performance increased for 95% of HCFs, from 49.9% to 70.7%, on average. During knowledge assessments participants verbally described accurate knowledge of IPC practices 28.0% of the time, with a higher proportion of participants from rural districts (40.8%) and medical doctors (55.6%) describing practices accurately. Based on observations, adherence to injection safety and high-level disinfection was high; weaknesses were observed for hand hygiene, waste management and spillage cleaning. Thematic analysis of qualitative data revealed strengths in the frequency of supervisions and SBMR assessments. Remaining challenges include insufficient infrastructure, supplies, and HCW IPC knowledge on implementation of IPC practices, such as hand hygiene. Conclusion: Although the comparison of baseline and endline SBMR results show progress, IPC knowledge and adherence to evidence-based practices remain low three years into the IPC project, further hindered by insufficient infrastructure and resources. Addressing the root cause of the identified gaps, such as ensuring sufficient IPC supplies and practical training, is critical for sustained IPC progress. These results will be used to improve the delivery of this multimodal IPC project.

Background: Inappropriate antibiotic prescribing drives unnecessary healthcare expenditures and antimicrobial resistance. In 2022, the U.S. issued over 200 million outpatient antibiotic prescriptions, with 30% considered unnecessary. Although the clinical effects of overprescribing are well-known, its economic impact at the state level is less studied. This study estimated the financial burden of unnecessary antibiotic use in Tennessee in 2022 and examined differences based on age, rural or urban settings, and antibiotic class. Methods The IQVIA Medical Claims and Longitudinal Prescription Claims databases were used to perform a cross-sectional study evaluating the cost burden of unnecessary outpatient antibiotics dispensed from retail pharmacies in Tennessee from January 1–December 31, 2022. Antibiotic prescriptions were categorized into three tiers based on appropriateness using ICD-10 codes, with only Tier 3 (unnecessary) prescriptions included in the analysis. Prescriptions were aggregated by National Drug Code (NDC). Minimum, maximum, and average unit costs were obtained from Lexidrug-UpToDate and multiplied by the dispensed supply to estimate prescription-level costs. These costs were aggregated and stratified by age, residence, and antibiotic class. Results Conclusion Unnecessary antibiotic prescribing imposes a substantial economic burden, with annual costs reaching up to $245 million and notable out-of-pocket expenses for patients, disproportionately affecting older adults, rural residents, and certain antibiotic classes. Targeted stewardship interventions focusing on high-cost medications and prescribing patterns can reduce costs and antimicrobial resistance. Future research should evaluate tailored interventions and policies to promote proper prescribing across diverse demographic and geographic settings.

Background: Up to 33% of methicillin-resistant Staphylococcus aureus (MRSA) colonized patients will subsequently develop an invasive MRSA infection. Intranasal treatment is necessary to eliminate MRSA in the nose, which is recognized as a primary carriage site. In our 542 bed, community, teaching hospital, we had implemented CHG daily bathing for targeted patient populations (patients in ICU and with central lines), but struggled to reduce MRSA bacteremia rates. We proposed adding nasal decolonization and expanding the target population to include MRSA-positive patients, as a method of reducing MRSA bloodstream infections. Methods: On July 21, 2025, a formal MRSA decolonization protocol, including twice daily mupirocin for five days, and daily CHG bathing was recommended for all ICU patients, regardless of MRSA history, and MRSA positive patients, on any inpatient unit. A MRSA decolonization order set went live on October 27th, 2025, and was automatically added to pre-existing ICU admission and central line maintenance order sets. Pre-and post-intervention National Healthcare Safety Network (NHSN) hospital-onset MRSA bacteremia standardized infection ratios (SIR) were compared, in addition to a monthly review of MRSA bacteremia rates per 1000 patient days and mupirocin administration. NHSN antimicrobial resistance module standardized resistant infection ratios (SRIRs), were also compared between 2024 and 2025. Result: The pre-intervention (January-June 2025) MRSA bacteremia SIR was 0.853, compared to a post-intervention (August-December 2025) MRSA bacteremia SIR of 0.405. This represents a 53% reduction in SIR (p=0.398). The outpatient MRSA BSI prevalence rate from emergency department visits stayed steady between the pre and post-intervention periods, at 0.095 and 0.094. Figure 1 shows the inverse relationship between the increase in mupirocin administration (utilizing a threshold of < 5 administered doses) and decrease in hospital-onset MRSA bacteremia. Figures 2 and 3 show the prior years’ variation and current decline in SRIRs for both MRSA bacteremia and lower respiratory tract specimens. A decreasing trendline was not observed for other organisms’ SRIRs, including vancomycin-resistant Enterococcus. Conclusion: MRSA bacteremia contributes to significant morbidity, mortality, and financial penalties for hospitals. CHG bathing alone for ICU and central line patients was inadequate to reduce MRSA bacteremia rates. A default order set for MRSA decolonization, including nasal mupirocin, added to all ICU admissions and central line maintenance orders, improved compliance with the recommended protocol. Our hospital experienced a reduction in MRSA bacteremia following the implementation of a standardized decolonization protocol, including the nares, for all ICU, central line, and MRSA positive patients.

Background: After three decades of declining tuberculosis (TB) incidence in the United States, case counts have increased annually since 2020, including an 8% rise in 2024. Undiagnosed TB poses a risk in healthcare settings because its clinical overlap with other respiratory illnesses can delay diagnosis and expose unprotected healthcare workers (HCWs) to active TB during routine job duties. Despite this risk, there is no standardized CDC definition of TB exposure for HCWs, resulting in variability in exposure investigations, notification, and follow-up. Safety-net hospitals such as Cambridge Health Alliance (CHA), a 300-bed health system, are increasingly affected by complex exposure events. Over the past year, seven patients with active pulmonary TB potentially exposed nearly 250 staff across six clinical areas, requiring multiple notification rounds despite prompt protocols, highlighting gaps in follow-up and uncertainty about actionable exposure definitions. Objective: Using the definition of employee exposure as ?15 minutes within 6 feet of a source case without mask/respirator, this study aimed to evaluate the effectiveness of post-exposure investigation protocols, determine TB screening test conversion rates among exposed employees, and assess the incidence of active TB disease during the study period. Methods: We reviewed email outreach to HCWs, employee communications, and TB testing records, and compared institutional practices with CDC and National Tuberculosis Controllers Association (NTCA) guidance. Analysis focused on accurate identification of exposed employees and completion of recommended follow-up testing using IGRA or TST. Results: Key barriers included incomplete exposure lists, fragmented interdepartmental communication, and inconsistent documentation of TB history,necessitating additional outreach efforts and contributing to a more time intensive notification process. The audit identified 243 potentially exposed staff, of whom 238 were contacted. 189 (79.4%) responded; non-responders included former employees, staff on leave, and those who did not reply. Among respondents, 87 (46%) met exposure criteria. Twenty-five (28.7%) had prior positive TB tests and were excluded from retesting. Of the 62 eligible for follow-up testing, 48 (77.4%) completed testing. No new TB infections or active TB cases were identified. Conclusions: Despite logistical challenges, the investigation achieved a high response rate with no new TB cases detected. Our study identified opportunities for improvement in data management, communication, and exposure classification. Standardizing TB exposure definitions and implementing centralized tracking systems may improve efficiency, consistency, and HCW protection. These findings support the effectiveness of current infection prevention measures while underscoring the need for a standardized national or regional approach.

Background: Inappropriate urine cultures without a clinical indication are sent frequently. Previous work has demonstrated that clinical decision support (CDS) requiring an indication for culture can reduce the number of unnecessary urine cultures. Our multi-campus VA facility implemented requirement of an indication for urine culture orders and evaluated the rate of urine cultures over time as well as the indications. Methods: We implemented a previously developed CDS menu across inpatient and outpatient services within VA Boston healthcare system. The CDS implementation required assistance and approval from our laboratory and clinical applications coordinators. Clinicians were notified about the change in ordering process through email and focused educational sessions. We captured rates of urine cultures by location and by indication and compared rates before and after implementation. A run-in period was allowed for full roll-out of the intervention, which was set at 98% of urine cultures being ordered through the CDS menu. This was a quality improvement initiative. Result: The study period included a 5-month pre-intervention period and a 5-month post-intervention period that followed a 2 month run-in period. A total of 2955 urine cultures were ordered preintervention compared with 2028 cultures postintervention. The average rate of monthly urine cultures decreased from 591/month to 406/month (P Conclusion: We demonstrated a significant reduction in urine culture orders using a clinical decision support intervention that required the ordering clinician to indicate a reason for the order. This intervention only required a targeted modification in our lab orders and was simple for clinicians to comply with given a drop down click menu. One limitation is that we did not capture clinical outcomes - but we did have continuous feedback from clinicians that did not indicate any adverse events, either in efficiency of practice or in outcomes among patients. This approach has been more successful at our hospital compared with other approaches that require system wide changes in urine culture processing or resulting. It has the added benefit of direct clinician education regarding appropriate urine culture indications in different settings.

Background: Invasive Staphylococcus aureus (SA) infections are a common cause of sepsis in premature infants admitted to the neonatal intensive care unit (NICU). While a quality improvement team effectively reduced methicillin resistant (MRSA) invasive infections, methicillin susceptible (MSSA) infections remained problematic. As a result, there was a renewed effort to understand MSSA infection transmission and reduce invasive MSSA infections. Methods: The primary outcome was invasive MSSA infection, most commonly bacteremia, in the NICU. Environmental cultures identified MSSA on high touch point areas and whole genome sequencing (WGS) confirmed there were both endemic strains and independently introduced strains. New interventions to reduce invasive SA infections included additional environmental cleaning of clinical workstations with effectiveness measured by fluorescent marking and a start of shift chlorhexidine (CHG) /alcohol (Avaguard) below the elbow wash for NICU staff. Babies were screened weekly for MSSA/MRSA colonization. Results: In 2023 and 2024 when there were no MRSA infections, there were nine MSSA infections (Figure 1). WGS confirmed that environmental MSSA strains were recovered from infants. Increased screening for MSSA with selective decolonization with mupirocin for high risk infants did not temporally change invasive infection rates and the mupA gene for high level mupirocin resistance was identified in a subset of colonizing strains. There were no significant changes in rates of new colonization for either MSSA or MRSA in 2025. After 1697 days there was one MRSA infection in September 2025. Introducing enhanced environmental cleaning and below the elbow disinfection for staff was temporally associated with a reduction in invasive MSSA infections with only two MSSA infections in 2025, most recently in March. As of January 1, 2026 the NICU has gone nine months without a MSSA infection. Conclusions: Increased environmental cleaning of clinical workstations with a start of shift below the elbow staff disinfection has resulted in a sustained reduction in invasive MSSA infection without a significant reduction in colonization rates. Additional work is ongoing to further understand if SA environmental colonization is reduced and whether current strains colonizing infants are identical to those that have caused invasive infection in the past.

Background: Hospital-acquired infections remain a significant challenge for healthcare systems despite well-established infection prevention (IP) strategies, with ventilator-associated infections (VAI) being particularly challenging. This is especially true for pediatric patients, who often require mechanical ventilation for extended periods, increasing the risk of infection. Gram-negative bacteria, primarily Pseudomonas aeruginosa, are the leading causes of VAI. Traditional IP strategies are often reactive and may miss potential transmissions within the hospital, particularly for pathogens that are endemic to the hospital environment. Whole-genome sequencing (WGS) and genomic epidemiology have demonstrated value in identifying such events in adult hospitals, but their application in pediatric facilities remains limited. Here, we conduct a retrospective analysis to determine how this technology could be utilized in a pediatric facility. Methods: We conducted a retrospective genomic surveillance study of Gram-negative isolates collected between 2020 and 2024 at a pediatric tertiary hospital. Briefly, clones were selected by colony morphology, cultured, and DNA was extracted. DNA libraries were prepared and sequenced on the Illumina NextSeq 1000 platform. Phylogenetic analyses were performed using core-genome alignment pipelines. Likely transmission events were defined as bacterial clones differing by fewer than 10 single-nucleotide polymorphisms, based on previously described literature. Genetically related clones were evaluated with patient location and temporal hospital metadata to assess epidemiologic linkage. Results: A total of 687 clones from roughly 500 clinical samples were sequenced. We identified over 50 groups of genetically related isolates from multiple Gram-negative species. P. aeruginosa accounted for most of the genetically related groups, with over 40 discovered. Additional pathogens suspected to have genetic relatedness include Serratia marcescens, Klebsiella pneumoniae, Stenotrophomonas maltophilia, and Achromobacter xylosoxidans. These groups range in size from 2 to 15 patients. Pairwise genomic analysis confirmed at least 16 groups consistent with likely transmission events. To date, epidemiologic review has confirmed that 2 of these groups were plausible based on temporal and geographic relationships between patients. The remaining 14 groups are under investigation. Conclusion: WGS-based surveillance identified multiple transmission events that were not recognized by conventional IP methods, highlighting the added value of WGS for hospital surveillance. This is especially true in the case of pathogens that are commonly found in hospitals. Integrating WGS with genomic epidemiology and hospital metadata can enhance patient safety and reduce healthcare costs. These findings indicate that reliance on traditional surveillance alone may underestimate the true burden of hospital outbreaks, particularly those caused by common Gram-negative respiratory pathogens in pediatric populations.

Auxinic herbicides (Group 4) are a crucial tool for maintaining effective weed management in modern agronomic systems. Palmer amaranth has evolved resistance to multiple herbicides, including auxinic herbicides. With documentation of auxin resistance in Palmer amaranth, new strategies should be implemented to improve management. Field studies were conducted in Tennessee during the summers of 2024 and 2025 to evaluate the efficacy of different herbicide application methods for managing auxin-resistant Palmer amaranth. The research compared tank-mixed applications of 2,4-D and glufosinate with split-applied (split-boom; herbicides applied simultaneously through separate spray booms as independent solutions) applications across multiple Palmer amaranth populations. Results demonstrated that in populations exhibiting high auxinic resistance, the split-boom application method was more effective than the conventional tank-mix approach. However, control levels were still below those typically considered acceptable for effective Palmer amaranth contol. Sequential split-boom applications were required to achieve acceptable levels of control in these populations. A second study evaluated whether carrier volume influenced the performance of these applications by comparing mixtures of 140 L ha-1 and 280 L ha-1. The results indicated that carrier volume did not significantly affect Palmer amaranth control at these volumes.