This article critiques the case-law of the CJEU on when Member States are ‘implementing’ EU law under Article 51 of the Charter, and tables a proposal for amending Article 51 to enhance the effectiveness of EU fundamental rights protection. It also suggests modifying and updating the explanations. Given that Member State judges have alternative routes available to them to resolve fundamental rights disputes, namely via Member State rules and the ECHR, and which do not require consideration of a complex threshold question before the pertinent substantive laws can apply, it suggests that review of Article 51 of the Charter might be timely.

Introduction: A vital factor indicating quality of care in hospital settings is hospital-acquired infections (HAI) occurrence, particularly bloodstream infections (BSI). Currently, BSI tracking through the National Healthcare Safety Network (NHSN) focuses primarily on central-line-associated BSI (CLABSI) and MRSA BSIs. Hospital-onset bacteremia (HOB) is a more comprehensive measure of HAI-BSI from all sources. Non-reportable BSIs account for a substantial number of HAIs and contribute significantly to patient outcomes, making them an important component for quality measurement and patient care improvement. NHSN has indicated that HOB reporting will be implemented within the next few years. Methods: This study establishes a baseline measure of HOB at Stony Brook University Hospital (SBUH) for 2022 and 2023. HOB cases were defined as any inpatient having at least one positive blood culture result, with the first positive culture collected ≥ 3 days after admission. Patient demographics, length of stay (LOS), and ICU admission status were compared among HOB and community-onset BSI (CO BSI) cases. Case mix index (CMI)-adjusted rates of HOB infection were generated for each hospital location by residualizing the rate of HOB infection on average annual CMI for each unit. Bivariate analyses were used to examine which hospital locations and medical devices were most frequently associated with HOB and CO BSI cases. Causative organisms were also examined. Results: A total of 1906 inpatients had positive blood cultures in 2022, 319 (16.74%) were HOB. In 2023, 1853 inpatients had positive cultures, 268 (14.46%) were HOB. Patients with HOB were significantly younger, and Medicare recipients represented the highest proportion of HOB cases. In both years, over 60% of HOB cases were admitted to an ICU compared to about 30% of CO BSI cases, LOS was about 3 times longer, and ICU LOS was more than two times greater for HOB cases compared to CO BSI cases. CMI-adjusted HOB infection rates were highest for MICU, SICU, CICU, and Oncology units, as well as one general medicine unit. All 9 medical devices examined were significantly associated with HOB in bivariate analysis, with central and peripheral IV catheters, urinary devices, arterial lines, and enteral tubes being most frequently present. Probable contaminant organisms were detected in > 50% of all positive cultures examined, but only probable pathogens were detected in > 50% of HOB cases. Conclusions: HOB has a significant impact on SBUH inpatients. Results from our study should be used to target infection prevention initiatives moving forward.

In this article, we will provide a new proof of the fact that for any convex body $K\subseteq \mathbb {R}^n$,

$$ \begin{align*}\frac{{{2n}\choose{n}}}{n^n}n\int_0^\infty r^{n-1}\mathrm{vol}_n(K\cap(re_n+K))dr\leq\frac{(\mathrm{vol}_n(K))^{n+1}}{(\mathrm{vol}_{n-1}(P_{e_n^\perp}(K)))^n}, \end{align*} $$

$(e_i)_{i=1}^n$

$\mathbb {R}^n$

$P_{e_n^\perp }(K)$

$e_n$

$\mathrm {vol}_k$

Background: Healthcare-associated infections (HAI) and multi-drug resistant organisms (MDRO) are a significant cause of morbidity and mortality in the hospital setting. Bacteria often colonize a patient’s skin and can become a source of infection. Bathing patients with chlorhexidine (CHG) has been shown to decrease colonization with MDROs, central-line associated bloodstream infection (CLABSI), and HAIs. The best method for applying CHG remains unknown and hospitals continue to employ different methods of CHG bathing. Methods: This was a nursing led quality improvement project due to staff shortages to reduce the workload burden of a 36-bed bone marrow transplant (BMT) and medical oncology unit. Prior to October 2023, all patients on the unit received a daily CHG bath with 4% CHG solution, which was the standard of care in the rest of the hospital. Beginning in October 2023 patients who were admitted or transferred to the unit had an initial bath with a 2% CHG wipe. Patients would then receive a daily CHG bath with a 4% CHG solution. If a patient were to refuse a bath with the 4% CHG solution, they would be offered a bath with the 2% CHG wipes. The goal of the quality improvement project was to improve compliance with daily CHG bathing, and to reduce HAIs. A pre/post analysis was performed assessing daily bathing compliance and HAIs and MDROS on the BMT unit for the 9 months before and after the intervention. Results: From January 2023 through September 2023, there were 9187 patient days on the unit, with 26 documented mucosal barrier injury (MBI) CLABSI (2.83 per 1000 patient days), 2 MRSA bloodstream infections, and 3 VRE bloodstream infections. From October 2023 through June 2024, there were 9176 patient days on the unit with 19 documented MBI CLABSI (2.07 per 1000 patient days), no MRSA bloodstream infections, and no VRE bloodstream infections. Daily CHG bathing compliance increased from 75% in the 3 months prior to the intervention, to 82% after the intervention. Conclusion: Utilizing a mixed method daily CHG bathing regimen that includes 2% CHG wipes increases compliance of daily CHG bathing, and decreases HAIs and MDROs compared to a regimen with only 4% CHG solution. HAI reduction could be accomplished through reducing microbial colonization on the skin, or possibly simply by increasing overall compliance. Further study on this could evaluate the reduction in workload burden, cost-effectiveness, and reduction in HAIs.

Background: It is challenging to identify a pathogen in most cases of community acquired pneumonia (CAP) as most available diagnostic tests either lack sensitivity or require an invasive specimen. S. pneumoniae urine antigen test (SPUAT), which detects the most common cause of bacterial CAP, has been used due to its higher sensitivity, non-invasive specimen collection, and more rapid turnaround time. However, the most recent IDSA/ATS guidelines only weakly recommend obtaining SPUAT as results have limited effects on clinical management given current CAP treatment guidelines. Our study aimed to determine whether use of the SPUAT resulted in meaningful changes in clinical management within the Emory Healthcare system. Method: We studied all patients within our 6-hospital healthcare system who had a SPUAT performed between 12/1/2023 and 11/30/2024 (n = 1258). Chart review for each positive SPUAT case was performed by two separate reviewers to identify change in management based on SPUAT, alternative diagnostic tests that identified S. pneumoniae, and time to positivity of alternative diagnostic tests. Disagreements were adjudicated by discussion between the two reviewers. Proportions and 95% confidence intervals were calculated using prop.test in R version 4.3.1. Result: There were a total of 66 positive SPUAT out of 1258 total tests resulted (5.3%, 95%CI 4.1% – 6.6%) over 12 months. In 18 of the 66 positive SPUAT cases, an alternative diagnostic test was also positive for S. pneumoniae. In these cases, blood cultures were the most common alternative positive test (14/18) while the second most common alternative test was the pneumonia pathogen panel (11/18). In the majority (13/18) of cases with positive alternative tests, the alternative test resulted prior to the SPUAT. The median time to result for the first alternative test was 9.5 hours sooner than the SPUAT (IQR -0.2 hours - 37.9 hours). In 15 cases, a positive SPUAT resulted in a change in antibiotic management (1.2%, 95%CI 0.7%-2.0%). In cases where there was a change in management, de-escalation of antibiotics was the most common change in management identified (Table). The number of tests required for one management change was 84 tests at an estimated cumulative cost of $2100. Conclusion: In our healthcare system, SPUAT had a low test-positivity rate and an even lower rate of management changes per test ordered at a high cumulative cost per management change.

Background: Antimicrobial-resistant pathogens cause more than 2.8 million infections and 35,000 deaths annually in the U.S. Risks for antimicrobial-resistant infections are likely tied to social determinants of health. We assessed the relationship between ADI and targeted MDROs reported (mandatory and voluntary) to the Philadelphia Department of Public Health (PDPH), specifically: carbapenem-resistant Enterobacterales, Acinetobacter baumannii, Pseudomonas aeruginosa and Candida auris. Method: Confirmed MDRO case data were obtained from PDPH’s Communicable Disease Management System, PhilaVax, and CDC’s National Healthcare Safety Network for 04/2018 through 12/2023. MDRO patient home addresses were geocoded to census block groups, spatially mapped to zip codes using ArcGIS, and matched to ADI national percentile rankings and state decile rankings obtained from University of Wisconsin School of Medicine and Public Health’s Neighborhood Atlas website. Descriptive analysis using American Community Survey Data, calculation of MDRO prevalence rates by zip code, and Pearson correlation coefficients and simple linear regression between the MDRO cases and ADI were conducted using SAS 9.4. Missing and unknown values were excluded from descriptive analysis. Result: We analyzed 2436 MDRO cases reported to PDPH. Cases with race data (n=2138) were 51.9% Black and 34.1% White, compared to 43.3% Black and 38.0% White Philadelphia County population in 2023. Hispanic ethnicity was reported for 8.6% of cases (n=2101), while Hispanics represented 15.8% of the county population in 2023. Most patients with MDROs were ≥60 yo (60.1%). That age group was 55.5% male compared to the 42.5% male ≥60 yo county population. Most MDRO cases, 1846/2436 (75.8%), matched to Philadelphia zip codes and 1515/2436 (62.2%) matched to a census block ADI ranking. Three zip codes had a prevalence rate of >20 (M = 12, SD = 8; range 2-53) per 10,000 persons. Home address history for 356/2436 (14.6%) cases matched one or more congregate facilities, the majority of which matched a long-term care facility (286/2436, 11.7%). ADI percentiles and deciles positively correlated with the number of MDRO cases, r(86) = .62, p <.0001 and r(8) = .82, p = .0036, respectively. There was a significant effect of ADI percentiles and deciles on number of MDRO cases, F1,86 = 53.4, p Conclusion: There is a significant positive relationship between ADI ranking and MDROs in Philadelphia. The findings suggest a critical need for equitable outreach and interventions to address MDROs in both congregate facilities and communities experiencing greater deprivation.

Background: State-level hospital comparative antibiotic usage rates can highlight opportunities for interventions to optimize antimicrobial stewardship (AS). We sought to characterize antibiotic usage rates for Nebraska hospitals stratified by hospital size and rurality. Methods: NHSN antibiotic use (AU) data reported from September 2023 to August 2024 was extracted. Hospitals reporting adult data for any antibiotics of interest were included in analysis. Data from all units reported by the hospital were included. Hospital sizes were categorized by number of beds reported to NHSN: critical access (≤25 beds), medium (26-150 beds), and large (>150 beds). Rurality was defined using the USDA rural urban commuting area codes: urban (1-3), semi-urban (4-6), and rural (7-10). AU rate was calculated using antimicrobial days of therapy over 1,000 days present. Pooled AU rates were used to provide a state rate by covariates and antibiotics. Descriptive statistics were used to describe prescribing patterns. A negative binomial regression model was used to understand the effect of hospital size and rurality on rate and one-way ANOVA to test significance. Results: AU data was analyzed for 51 facilities including 7 large hospitals (14%), 16 medium-sized hospitals (31%), and 28 critical access hospitals (55%). Of these, 27 facilities (53%) were located in rural and 9 (18%) in semiurban areas (Table 1). The top 5 antibiotics used were cefazolin, ceftriaxone, piperacillin/tazobactam, vancomycin, and cefepime (Figure 1). Although, there were no significant variations in total AU based on hospital size and rurality, some significant differences were noted when broken down by specific antibiotics (Figures 2 and 3). Critical access hospitals reported 1.8 times higher AU rate for ceftriaxone [95% CI: 1.2, 2.7], 2.2 times the rate for fluoroquinolones [95% CI: 1.3, 3.7], and 2.3 times the rate for azithromycin [95% CI: 1.4, 3.7], compared to large hospitals. Similarly compared to urban hospitals, rural hospitals reported 1.9 times higher AU rate for ceftriaxone [95% CI: 1.4, 2.5], 2.3 times the rate for fluoroquinolones [95% CI: 1.6, 3.4], and 2.2 times the rate for azithromycin [95% CI: 1.6, 3.2]. No significant difference was noted in the use of any antibiotics when comparing semiurban to urban and medium to large size hospitals. Conclusions: Significant variation exists in use of some antibiotics based on the hospital size and rurality. NHSN AU data can be leveraged to identify potential AS targets across various hospital settings.

Background: Targeted admission screening of high-risk patients for antimicrobial resistant organisms (AROs) is a key component of infection prevention and control. However, adherence with screening is suboptimal, risking a negligible impact on the prevention of ARO transmission. Clinical decision support tools in clinical information systems (CIS) may improve ARO screening adherence. This study evaluated the adherence of ARO admission screening using a tool in the provincial CIS in Alberta, Canada and the relationship between adherence and hospital ARO rates. Methods: A population-based, sequential cross-sectional study was completed on all admissions to acute care and acute rehabilitation facilities where ARO admission screening occurs on any unit, and where the CIS was implemented in Alberta between January 1, 2020 and March 31, 2024 (n=100). Mental health facilities/units, continuing care, newborns Results: There were 97 (97% of eligible facilities) facilities that implemented the CIS across seven launch periods included. Overall adherence ranged from 43% to 65%. After controlling for bed size and health zone, adherence decreased by the number of months each facility was active on the CIS (aIRR 0.987, 95%CI 0.986-0.987). There was no seasonality in trends. There was a negative relationship between adherence and overall MRSA infection rate (rs = -0.68) and after adjusting for bed size, health zone, and number of months active on the CIS (aIRR 0.99, 95% CI 0.986-0.994). Analysis could not be completed for CPO due to small numbers. Conclusions: While increased ARO admission screening adherence was associated with lower overall MRSA infection rates, the IRR was close to one and may not be clinically significant. With adherence decreasing over time, further work is needed to understand barriers to ARO admission screening and implement strategies to support healthcare providers in completing appropriate surveillance for AROs.

Background: Neonatal intensive care units (NICU) are associate with a high level of antibiotic consumption. Appropriate antibiotic use is crucial to minimize the emergence of resistance and unintended consequences to the patient. Our antimicrobial stewardship program (ASP) performed a baseline review of NICU antibiotic prescribing, which revealed excessive meropenem use and inconsistent empiric antibiotic prescribing practices within the unit. Third generation cephalosporins were vastly underutilized due to concerns of increased Candida infections resulting in the unwarranted excessive use of meropenem.1 Methods: In 2023, the ASP created an institution specific empiric NICU sepsis guideline to align empiric prescribing practices with current guidelines and reduce the unwarranted use of carbapenems. After education and guideline implementation, a retrospective review, pre (April 16, 2021 to April 16, 2023) and post (April 17, 2023 to April 17, 2024) implementation was conducted. The primary objectives were to evaluate the effect of the guideline implementation on antibiotic days of therapy (DOT) per 1000 patient-days, overall meropenem and third generation cephalosporin utilization, differences in the incidence of Candida infections, and variations in antimicrobial sensitivity. Microbiologic data from sterile site cultures were obtained April 2021 to March 2023 and post-implementation (April 2023 to March 2024) to evaluate cephalosporin and meropenem resistance for each period. Results: Meropenem DOT/1000 patient-days declined from 3.9 to 2.0 (51.3%), and an associated rise in third-generation cephalosporin DOT/1000 patient-days from 15.7 to 22.9 (69.7%) occurred post-guideline implementation. There were no observed differences in the incidence of Candida infections, cephalosporin resistance in Gram-negative bacilli, or the organisms isolated over the observation period. Conclusions: Guideline implementation safely and successfully reduced the use of carbapenems by providing alternative antibiotic regimens encouraging the use of third generation cephalosporins and reduced antibiotic pressure in our NICU. There were no differences in the incidence of Candida infections, organisms, or resistance patterns. Implementation of this guideline resulted in safe decreases in antibiotic use in the NICU.

Cotton CM, McDonald S, Stoll B, et al. The association of third-generation cephalosporin use and invasive candidiasis in extremely low birth-weight infants. Pediatrics. 2006;118(2):717-22.

Introduction: Studies examining carbapenemase producing carbapenem resistant Enterobacterales (CP-CRE) transmission incorporating clinical and genomic data in Indian hospitals are lacking. We investigated the prevalence, risk factors for CP-CRE peri-rectal colonization on admission and acquisition during hospital stay and genomic epidemiology of CP-CRE isolates in an adult surgical intensive care unit (SICU) in a tertiary-care hospital in India. Methods: SICU patients admitted from July 31 to November 30, 2023 were prospectively enrolled. Peri-rectal swabs (PRS) were collected at SICU admission and discharge, and hospital discharge. Environmental sampling of sinks was performed. Swabs were plated on selective agar (CHROMagarTMmSuperCARBATM) for CP-CRE isolation. Whole genome sequencing of CP-CRE isolates was performed to investigate antimicrobial resistance gene (ARG) abundance, strain typing (ST), and relatedness classified by community-associated (CA), healthcare-associated (HCA), hospital-acquired (HA), and environmental isolates. Results: 56 (28%) of 203 enrolled patients were colonized with CP-CRE on SICU admission. Among 147 admission-negative patients, 113 had repeat PRS testing > = 1 times during their stay; 43 (29%; 43/147) acquired CP-CRE (Figure 1). The predominant organism in admission and acquisition cases was Escherichia coli (52%) and Klebsiella pneumoniae (37%), respectively (Figure 2). Previous hospitalization = 2 antibiotics (aOR 2.77; 95%CI 1.12-6.82) were associated with admission CP-CRE colonization (Figure 3). In Cox regression analysis hospital stay before SICU admission was associated with CP-CRE acquisition in the SICU, but no risk factor was associated with acquisition during the entire hospital stay (Figure 4). Abundance of ARGs was lower in CA CP-CRE isolates compared to HCA, HA and environmental isolates (Figure 5). blaNDM and blaOXA genes were present in 79% (99/126) and 29% (36/126) of isolates, respectively; blaNDM-5 was the most common carbapenemase [65 (52%) of 126 isolates] (Figure 6A). E. coli ST410, which was associated with HA and HCA classifications was the most frequent ST (n=17) and 70% (12/17) carried NDM (Figure 6B). Twenty-seven E. coli and 17 K. pneumoniae isolates were separated by 20 or fewer core genome single-nucleotide polymorphisms, indicating potential relatedness amongst CP-CRE (Figure 7). Conclusion: More than 25% of SICU patients were colonized with CP-CRE on admission and also acquired CP-CRE during hospital stay. Healthcare-related CP-CRE isolates carried more resistances genes with NDM being the most commonly detected resistance gene in this cohort. Small sample size limited our understanding of risk factors associated with CP-CRE acquisition in hospital.

El presente ensayo examina los modos en que la novela Cadáver exquisito (2017), de la escritora argentina Agustina Bazterrica, habita y desafía la lógica capitalista de la cadena de montaje a través de estrategias literarias que a la vez encarnan y cuestionan el neoliberalismo exacerbado. El trabajo inicia con el rastreo de una propuesta teórico-crítica sobre trayectos literarios de la carne (Giorgi 2014) para luego analizar cómo el texto de Bazterrica dialoga con los conceptos de necroescritura (Rivera Garza 2013), mal de archivo (Derrida 1997) y montaje literario (Benjamin 2004a, 2004b). Este abordaje revela el modo en que diversas estrategias literarias —incluyendo el ensamblaje de escenas desmembradas, el uso del collage verbal, la función performativa del lenguaje, el desplazamiento metafórico-metonímico de las palabras y la tensión generada por eufemismos— socavan la práctica mecanicista y mercantilizante de la producción en serie de cuerpos y lenguajes. El artículo cuestiona, así, la interpretación de Cadáver exquisito como alegoría necropolítica, explorándola, en cambio, como dispositivo estético-político que tensiona las relaciones entre carne y palabra, interrumpiendo los principios rectores de acumulación y violencia que sustentan al sistema capitalista.

Background: Our Candida auris surveillance protocol dictates that all patients who have been admitted to a skilled nursing facility (SNF), long-term acute care hospital (LTACH), and/or acute inpatient rehab (AIR) in the prior six months be screened on hospital admission. When hospital-onset (HO) cases are identified, point prevalence surveys (PPS) are conducted. Despite this, we identified two units with high prevalence of C. auris and an increasing number of HO cases. To investigate, we initiated an expanded C. auris screening pilot. Methods: Infection prevention (IP) verified that two units, the medical intensive care unit (MICU) and the pulmonary medicine unit (PMU) had the highest C. auris prevalence and number of HO cases. We formed a multidisciplinary process improvement team (MPIT) to develop recommendations. A pilot was launched to implement universal admission and transfer screening by PCR and weekly screening by culture on MICU and PMU. Screening consisted of two swabs: bilateral nares and bilateral axilla/groin. For patients with a tracheostomy or endotracheal tube, an endotracheal aspirate was collected. Pilot data were analyzed and shared with executive leadership. Results: In the 15 months prior to the pilot, 24/47 (51%) of the hospital-wide HO C. auris cases occurred on the pilot units resulting in 17/40 (43%) of all PPS performed. The pilot, conducted between 5/7/24 – 8/24/24, screened 868 unique patients and detected 9 present-on-admission (POA) C. auris cases and 8 HO C. auris cases (Figure 1). This surveillance avoided a minimum of 7 PPS and identified a cluster of C. auris on MICU. Notably, 9/9 (100%) of the POA cases were exposed to a SNF, LTACH, and/or AIR within 6 months prior to admission. Of the HO cases, 7/8 (88%) were epidemiologically linked with another C. auris patient, and 4/8 (50%) were co-colonized with at least one other multidrug-resistant organism at the time of collection. The pilot was established as routine practice on the two units. Conclusion: Our screening pilot identified POA and HO C. auris cases and demonstrated that HO cases decreased over time. This suggests that active surveillance allows for rapid identification and isolation of patients, preventing transmissions and outbreaks. In our experience, IP education and hospital-wide admission screening did not stop cases on units with a high prevalence of patients with C. auris. The pilot confirmed that our current hospital-wide admission screening protocol identifies cases on admission but alone will not prevent nor capture HO cases.

The nonlinear Schrödinger equation is a second-order nonlinear, integrable partial differential equation describing the propagation of nonlinear waves in a variety of media, including light propagation in optical fibres. Inspired by recently reported experiments, here we consider its generalization to higher, even orders, of derivatives corresponding in optics to higher orders of dispersion. We show that none of these equations are integrable and investigate the nature of singularities that cause the equations to fail the Painlevé test.

Background: Surgical site infections (SSIs) following cesarean deliveries (C-sections) result in excess morbidity, mortality, and healthcare expenses in resource-limited countries such as Bangladesh. Over the past two decades, C-section rates have increased dramatically in Bangladeshi hospitals, and comprehensive data on SSI after cesarean delivery, which is vital for the improvement of maternal health outcomes, remains limited. In this study, we assessed the prevalence of SSIs including their determinants among patients undergoing C-sections in Bangladesh. Methods: From May to December 2023, we conducted a prospective observational study at six tertiary hospitals (3 public and 3 private) in Bangladesh. Participants were hospitalized pregnant women who had undergone C-sections. The WHO-guided methodology and tools were employed to acquire the data. Participants were systematically evaluated on days 1-3, 7, 14, and 30 of surgeries, with a rigorous inquiry into symptoms such as fever, abdominal pain, localized swelling and redness, wound dehiscence, and purulence or abscess. The SSI diagnosis was confirmed based on at least two present symptoms, or a physician’s assessment, or microbiological confirmation within the 30-day post-operative window. Descriptive and multivariate logistic analyses were performed to determine the prevalence and factors associated with SSI. Results: Of 1335 participants enrolled, the overall prevalence of SSIs was 19.1% (255/1335, 95%CI: 17.6-21.5), with public hospitals having almost twice as SSIs at 21.6% (215/995) compared to private hospitals (11.8%, 40/340). More than half of the patients (54.8%) were found with at least two SSI symptoms within the 7 to 14 days of follow-up. Approximately half of the patients (49.2%) had a history of previous C-sections. The C-sections performed in private hospitals were predominantly on an emergency basis (85.1%) compared to public hospitals (56.2%). The multivariate analysis identified key determinants of SSI following C-section were patients with prolonged labor > 18 hours (AOR: 2.2, 95%Cl: 1.16, 4.13), fetal distress (AOR: 1.82, 95%Cl: 1.33, 2.49), premature rupture of membrane (PROM) > 12 hours (AOR: 1.70, 95%Cl: 1.05, 2.75), and high BMI (AOR: 1.69, 95%Cl: 1.27, 2.25). Conclusions: This study highlights the burden of SSIs following C-sections in tertiary hospitals in Bangladesh, particularly in public healthcare settings. The findings highlight the critical need to enhance infection prevention and control measures to mitigate the occurance of SSIs within these healthcare settings.

We consider the problem of computing a class of soliton gas primitive potentials for the Korteweg–de Vries equation that arise from the accumulation of solitons on an infinite interval in the physical domain, extending to $-\infty$. This accumulation results in an associated Riemann–Hilbert Problem (RHP) on a number of disjoint intervals. In the case where the jump matrices have specific square-root behaviour, we describe an efficient and accurate numerical method to solve this RHP and extract the potential. The keys to the method are, first, the deformation of the RHP, making numerical use of the so-called g-function, and, second, the incorporation of endpoint singularities into the chosen basis to discretize and solve the associated singular integral equation.

Introduction: Pre-authorization and prospective audit and feedback, though effective interventions for reducing antibiotic use, require manpower, time and can impinge on prescriber autonomy. We describe a unique approach to optimizing antibiotic use. Methodology: The antimicrobial stewardship program at our hospital is physician-led and supported by clinical pharmacists. To reduce time and manpower, we adopted a collaborative approach of structured audits. A baseline phase measured antibiotic consumption, mapped antibiotics to clinical syndromes, and documented inappropriate antibiotic use about choice, dose and duration. We then went to an intervention phase where for a month, prospective audit and feedback was performed for all the patients in the department in real time, communicated and discussed with a liaison from the treating team. At the end of this period, we presented data regarding antibiotic consumption and the proportion of justified antibiotic use in terms of choice, dose, and duration compared to the baseline phase. Literature evidence of appropriate antibiotic use was presented along with actionable data where gaps had been identified. Results: Structured thematic audits were conducted across seven key departments, including Medicine, Surgery, Orthopedics, Obstetrics and Gynecology, Urology, Hematology, and Emergency Medicine. As an example, the data on Orthopedics is presented here. The audit was done over one month across three general wards, and 94 patients were recruited. The antibiotic consumption was DOT/100PD=78.2, and the average length of therapy was 6.2 days. The antibiotic utilization for the broad infectious specific syndrome is shown in Table 1. Non-infective elective surgery and closed fracture received 4.4 and 5.6 mean days of antibiotics, which was deemed unnecessary. However, no institutional antibiotic protocol for open fractures (considered contaminated) existed. On discussion with the entire orthopedics department, a consensus was reached on antibiotics for open fractures with or without contamination for a maximum of 72 hours or until wound closure. Other areas where antibiotics could be optimized according to standard guidelines were also agreed upon and reinforced. This meeting resulted in consensus building and collaborative clinical decision pathways adopted into our institutional antibiotic guidelines. Conclusion: This unique thematic structured audit approach enhanced judicious antimicrobial prescribing practices, leading to consensus building across the hospital. It also led to changes in policy, fostering ownership and breaking the hierarchical model of stewardship, shifting accountability to the primary departments. It also reduced the time and resources required for the AMS team.

Background: The transmission of plasmids carrying antimicrobial resistance (AMR) genes between patients poses a significant global health challenge. The New Delhi metallo-β-lactamase (NDM) carbapenemase is associated with high mortality and limited therapeutics. Traditional Infection Control surveillance for intra-institutional organisms carrying AMR genes relies on retrospective clinical and epidemiologic review. Whole-genome sequencing (WGS) has been utilized to detect outbreaks, including those not clinically apparent within healthcare settings. In this study, we sought to identify related NDM-carrying Escherichia coli using WGS. Method: NDM-carrying E. coli isolates in clinical cultures were identified between November 2023 and October 2024. Bacterial genomic DNA was extracted directly from clinical microbiology laboratory plates. Sequencing was performed using the Oxford Nanopore Technologies MinION platform with an R10.4.1 flow cell. Assembled FASTA files from the in-house Flyest pipeline were analyzed with AMRFinderPlus to detect AMR genes. Plasmid replicons were identified using staramr. Horizontal plasmid transfer annotation was conducted using Roary, which incorporates Prokka, and pairwise single nucleotide polymorphism distances were assessed with snps-dist. Results: Nine E. coli strains producing blaNDM-5 were identified from eight patients. Two isolates from one patient showed high genetic similarity, indicating they were likely the same strain. The identified sequence types (STs) were ST361 (4 strains), ST167 (3 strains), ST205 (1 strain), and ST405 (1 strain). Four strains harbored a hybrid IncFIA/IncFIB(AP001918) plasmid, demonstrating 99.8%–99.9% nucleotide similarity. This plasmid carried blaNDM-5, blaCTX-M-15, blaOXA-1, and efflux pump-related genes, contributing to multidrug resistance. Despite the high plasmid similarity, no obvious epidemiological links, such as overlapping patient admissions or common procedures, were identified among the four patients carrying this hybrid plasmid. Conclusion: WGS presents a novel modality to identify highly genetically related strains of organisms within a healthcare institution that may reflect silent outbreaks or AMR dissemination not detected by conventional Infection Control methods.

Background: It is estimated that 28% of all oral antibiotics prescribed in outpatient care in the United States are inappropriate.1 Most hospitals have established antimicrobial stewardship programs (ASPs) that focus on inpatient antimicrobial stewardship2,3 however, less is known about the engagement of hospital ASPs in outpatient clinics. The goal of this project was to explore the extent to which ASP activities in hospital affiliated clinics align with current guidance for outpatient antibiotic stewardship and challenges to applying hospital based interventions in outpatient settings. Methods: The study population comprised 288 hospitals that participated in two previous antimicrobial stewardship studies4. Hospitals needed to have an active outpatient ASP to be included. We conducted in-depth telephone interviews with ASP leaders from 28 diverse hospitals. We used MAXQDA 20225 for data analysis and the framework method6 to organize and analyze interview transcripts based on 4 CDC Core Elements for Outpatient Stewardship.7 Results: The sample included 11 large, 9 medium, 8 small hospitals with various outpatient settings (Figure 1). Commitment. Few hospital ASPs had a dedicated outpatient stewardship leader. Around half the hospitals included outpatient sub-committees or representatives on the ASP committee. Only one hospital had a formal stewardship lead at the clinics while others relied on local contacts and EHR system-based interventions. Tracking and reporting. Most hospitals in the sample reviewed outpatient specific data, though many had no data analyst or IT resources for outpatient data. Action. Hospitals in our sample differed widely regarding development of decision-support tools. Only some developed guidelines tailored to outpatient settings, a few of them distributed via CDSS requiring indications for prescriptions, whereas others simply made inpatient guidelines available to clinicians. Education. Only some hospital ASPs developed content tailored for outpatient. Key challenges for expansion of stewardship into outpatient settings included lack of funding, and dedicated staff; lack of clarity regarding best practices for measurement; and an outpatient EHR infrastructure that limited effective guideline distribution and measurement. Conclusions: Outpatient stewardship programs were aligned with current guidance, although frequently missing outpatient-specific committee representation, data and education. Few hospitals received additional resources for expansion into outpatient stewardship and most lacked dedicated leaders at clinics, putting additional burden on inpatient ASP leads. While some hospitals have developed guidelines, tracked prescriptions, and provided clinic or clinician feedback, there is need for investment in staff and EHR infrastructure to improve outpatient-specific guideline development, distribution and measurement.

Background: Blood cultures are essential for the accurate diagnoses of sepsis and bacteremia and have been recommended and used liberally as part of the diagnostic workup. Previous studies have shown that judicious use of blood cultures is safe in both adults and children (PMID 31942949). In the summer of 2024, BD BACTEC experienced a national shortage of blood culture media bottles, prompting institutions nationwide to implement measures to conserve supplies. Our institution rapidly implemented a blood culture diagnostic stewardship program, adopting a tiered approach including refining guidelines for blood culture orders via institution-wide education, and leveraging EMR both via best practice advisories (BPAs) on appropriate culturing and ordering restrictions. In this study, we evaluate the impact of these interventions and the post-restriction effects of EMR-based education. Methods: Prior to the shortage, no clinical decision support existed in the EMR to guide the blood culture ordering process. Initial measures implemented in July 2024 included a BPA highlighting appropriate indications for ordering initial and follow-up blood cultures (PMID 39136555; ASM Blood Culture Bottle Inventory Management and Clinical Conservation During Supply Shortages). In August 2024, restrictions were introduced, limiting orders to one set per 72 hours, with case-by-case overrides managed by an Infectious Diseases-led diagnostic stewardship team. After supplies improved in November 2024, restrictions were lifted, but the BPA-based clinical guidance was retained. Blood culture volumes were monitored across three phases: pre-shortage, during restrictions, and post-restriction. Results: Blood culture volume decreased by approximately 50% immediately following the introduction of BPAs and further decreased to 75% of pre-shortage levels during the restriction period. Post-restriction, at 2 months follow-up, culture volume has stabilized and sustained at over 50% lower than pre-shortage levels. Conclusion: The implementation of in-EMR best practice guidance, and temporary restrictions during a blood culture media shortage, led to significant reductions in blood culture order volume, even after lifting restrictions. These findings support the role of diagnostic stewardship interventions in promoting lasting changes in provider behavior. Utilizing EMR to support best practices and aligning blood culture practices with evidence-based indications, can reduce unnecessary testing and improve resource utilization. Further research is needed to evaluate the impact of these changes on patient outcomes.