Introduction: Community-acquired pneumonia (CAP) is the leading infectious cause for hospitalization. Guidelines recommend use of a macrolide antibiotic with a beta-lactam for coverage of atypical organisms; however, data supporting macrolide coverage disproportionately include patients with severe CAP. Debate remains regarding the benefit of macrolide coverage among patients hospitalized with non-severe CAP. Methods: We emulated a target trial to evaluate outcomes associated with azithromycin use among patients hospitalized with non-severe CAP between 7/2017 and 8/2024 across 69 hospitals in Michigan. Included patients had an ICD-10 discharge diagnosis code of pneumonia, >2 signs or symptoms of CAP, and radiographic findings. Patients with severe CAP, risk factors for multi-drug-resistant organisms, those not started on standard CAP therapy with a narrow-spectrum beta-lactam with or without azithromycin, or those initially receiving doxycycline were excluded. Time zero was the time of first antibiotic administration on encounter day 1 or 2. Groups receiving and not-receiving azithromycin were balanced using inverse probability of treatment weighting (IPTW) assessed using standardized mean differences (SMD). The primary outcome was time to clinical stability. Secondary outcomes included intensive care unit (ICU) transfer, 30-day rehospitalization, 30-day mortality, and protocol deviation (i.e., azithromycin initiation after time zero [no-azithromycin group], patients receiving <5 days of azithromycin [azithromycin group]). We used the Cox model and multivariable Poisson regression for time-to-event and binary outcomes, respectively. Based on point prevalence of outcomes within our cohort, we were well powered to detect the demonstrated relative differences in all outcomes. Results: Of the 59,698 patients meeting criteria for pneumonia, 19,108 patients were included in the final post-exclusion cohort. Of these, 93.7% (17,904/19,108) received azithromycin on day 1 or 2 (median antibiotic duration 4.0 days [IQR 3,5]), while 6.3% (1,204/19,108) did not. After IPTW, groups receiving and not-receiving azithromycin were well balanced (SMDs <0.1). After adjustment, median time to clinical stability did not differ between the azithromycin and no-azithromycin groups (3 vs 3 days; HR 1.01 [95% confidence interval 0.97–1.14], p=0.74), nor did rate of ICU transfer (0.9% vs 1.3%; HR 0.90 [0.51–1.62], p=0.73). Patients receiving azithromycin had lower rates of 30-day rehospitalization (10.8% vs 15.3%, HR 0.69 [0.58–0.82], p<0.001) and 30-day mortality (2.3% vs. 4.0%; HR 0.70 [0.50–0.93), p=0.03). Protocol deviation occurred more commonly in those initially receiving azithromycin (56.5% vs 11.1%; HR 1.58 [1.32–1.82], p<0.001). Conclusions: Addition of azithromycin to beta-lactam therapy in patients hospitalized with CAP did not influence short-term outcomes but may reduce 30-day rehospitalization and mortality.

Background: Carbapenem-resistant Enterobacterales (CRE) are reportable statewide with required isolate submission to the Minnesota Department of Health (MDH) Public Health Laboratory (PHL), where carbapenemase production and mechanism identification is confirmed. MDH reviews all detected carbapenemase-producing organisms (CPOs) for potential transmission. Suspected transmission clusters are assessed for relatedness using whole genome sequencing (WGS). In 2022, increased detection of multiple bacterial genera of Klebsiella pneumoniae carbapenemase (KPC)-CRE occurred at acute care hospital-A, (ACH-A) and in 2023 the increase in KPC-CRE was accompanied by an increase in New Delhi metallo-β-lactamase (NDM)-CRE detection. Methods: MDH partnered with ACH-A to review increased CPO detection. MDH-PHL conducted WGS including multilocus sequence typing (MLST) and single nucleotide polymorphism (SNP) analysis on isolates. WGS suggested clusters of relatedness spanning multiple years and epidemiologic data revealed common room occupancy. Infection prevention and control (IPC) principles were reinforced in cluster areas and audits verified adherence, prompting consideration of an environmental reservoir. An environmental screening plan was developed focusing on sink drains from common rooms. In May 2024, 94 swabs from sink drains were collected and CPO culture-based screening was conducted using selective media followed by molecular testing of bacterial growth by MDH-PHL. Results: There was detection of CPOs from 28 of 94 (29.8%) sink drains. Eight environmental KPC-CRE isolates and one NDM-CRE isolate appeared genetically related to 22 unique patients over a 10-year period (Figure 1). Three sink drain isolates showed genetic similarity to each other, but not to patient isolates. Three CPO clusters, representing 14 patients, had genetically similar isolates without an associated environmental isolate. However, isolates were collected over months to years suggesting an undetected reservoir. In August 2024, ACH-A initiated mitigation strategies to prevent CPO transmission from environmental reservoirs, including modification of sink plumbing, maintaining a splash zone, refraining from disposal of bodily fluids in sinks, optimizing sink hygiene, and monthly screening of inpatients in units with known CPO sink contamination. From August to December 2024, 325 patients were screened with 1.2% of specimens detecting KPC-CRE colonization. Conclusion: Sink drains containing CPOs on multiple hospital units that correlated with patient cases were identified at ACH-A. WGS suggests intermittent transmission of different CPOs over 10 years, and clusters of transmission appear to be related to environmental sources. Strict implementation and adherence to IPC measures, including those that minimize the spread of CPOs from facility premise plumbing, are critical to prevent CPO transmission despite widespread premise plumbing contamination.

Background: Carbapenem-resistant Enterobacterales (CRE) have become an increasing public health challenge in the United States over the past two decades. Carbapenemase-producing CREs (CP-CREs) significantly contribute to the spread of antimicrobial-resistant pathogens in healthcare settings. Tennessee has been conducting surveillance of CRE since 2011. As part of the Emerging Infections Program (EIP), the state has participated in population-based surveillance in Davidson and seven surrounding counties, collaborating with the Centers for Disease Control and Prevention (CDC) since 2014. Methods: The data collected through the Muti-site Gram-negative Surveillance Initiative (MuGSI) project, a collaboration between Tennessee and CDC as part of EIP, was used for this study. The analysis was performed on a subset of CRE isolates tested for carbapenemase production (CP) among all incident CRE cases collected from 2016 to 2022. Incident CRE cases are defined as the identification of carbapenem-resistant E. coli, Enterobacter cloacae complex, and Klebsiella species (K. aerogenes, K. oxytoca, K. pneumoniae, and K. variicola) from urine or normally sterile specimens (e.g., blood) from the residents of the surveillance area in a 30-day period. The mortality data was obtained from the Tennessee Vital Registry and merged with the surveillance data. Cox regression analysis was performed to evaluate if there is a difference in the 90-day survival rate based on the CP status of the pathogen, gender, age group, and the Charlson comorbidity index (CCI) score. Data analysis was done using SAS version 9.4. Results: There were 570 CRE cases reported during the study period (2016-2022). Of these, 406 were tested for carbapenemase production and 87 (21.4%) were positive for CP. There were 269 (66.3%) females and 137 (33.7%) males. Patients with higher Charlson comorbidity index score (> = 5) have significantly higher hazard ratios compared to those with low scores (HR 4.17; p-value) Conclusion: This study indicates that patients infected with CP-CRE, females, and those with high Charlson comorbidity index score have a significantly higher probability of dying within 90 days. These factors are worth considering when conducting a risk assessment of patients infected with drug-resistant gram-negative bacilli. The significantly increased risk of death among patients infected with CP-CRE highlights the need for timely carbapenemase testing and use of the test result for appropriate antimicrobial therapy and infection prevention.

Background: Urine cultures are the gold standard for urinary tract infection (UTI) diagnosis and are becoming increasingly important to guide antibiotic choice. However, when samples are not collected properly they can become contaminated. In our primary care safety-net clinics, 694 (55%) of all urine samples collected from non-catheterized patients were contaminated, which led to one in five patients receiving unnecessary antibiotics and a waste of lab resources. We have developed a bilingual (English and Spanish), multicultural educational intervention that includes an animated instructional video and a flyer with pictorial instructions providing step-by-step guidance for collecting a midstream clean catch (MSCC) sample. Methods: A patient advisory board (PAB) was assembled to review our materials, recruiting patient representatives from 2 private and 2 public primary care clinics in Harris County. The PAB included 7 Hispanic patients (2 female), 3 Black patients (2 female), and 2 White patients (1 female), of which half were bilingual (50%). Each board member received a urine sample collection kit plus our educational flyer. One-on-one interviews were conducted with each PAB member, during which the educational video and flyer were shown. Using thematic analysis, the interview data was condensed into themes. (Figure 1) Results: There was a lack of awareness of how to collect a MSCC among patients. Most found the educational material to be helpful in clarifying the process, and the graphical elements were especially appreciated by those with difficulty reading. Patients reported confusion around appropriate use of the wipes and lack of pictorial directions for handwashing. Physical impediments reported by patients with the MCSS process included difficulty balancing and stopping urine flow for a mid-stream sample, particularly for elderly females with medical comorbidities. Conclusions: Our educational intervention was well received by a sociodemographically diverse group of patient representatives with minimal improvements needed. Future work involves implementation of this educational intervention into primary care workflows and evaluating its effectiveness in reducing urine contamination. Acknowledgments: This work is funded by R01HS029489-02 from the Agency for Healthcare Research and Quality (AHRQ). Dr. Collazo is funded by the Department of Health and Human Services, Health Resources and Services Administration (T32HP10031).

Welfare regime theory remains a central framework in social policy literature, valued for its theoretical insights and policy relevance. However, as this framework is increasingly applied to countries in the Global South, scholars have questioned whether all contexts fit neatly into the established welfare regime types. Recent contributions suggest adopting a hybrid lens, which recognizes that welfare arrangements often vary within the same country, with different populations experiencing distinct forms of social protection. This study contributes to this evolving debate by exploring the development of Iraq’s welfare system and proposing a hybrid classification within the welfare regime framework. We argue that Iraq functions as a hybrid welfare regime, where access to welfare and social protection is unevenly distributed across different segments of society. In doing so, the study extends welfare regime theory by classifying Iraq as a case of hybrid welfare regime and highlights the importance of hybrid welfare models for understanding welfare systems in the Global South.

We discuss a conjecture of Shokurov on the semi-ampleness of the moduli part of a general fibration.

Background: In 2024, The Joint Commission (TJC) introduced Standard IC.07.01.01 to bolster hospitals’ preparedness for high-consequence infectious diseases (HCIDs) such as novel Influenza, Ebola, and SARS-CoV-2. The standard emphasizes the need for an effective framework for managing emerging pathogens. While a definitive list of HCIDs does not exist, TJC defines HCIDs as, “novel or reemerging infectious agents characterized by high transmissibility, limited or no medical countermeasures, high mortality, and a need for rapid identification and stringent infection control.” We outline the process of developing a policy at a National Cancer Institute-designated cancer center to ensure prompt and efficient management of suspected HCID cases. Methods: The policy development process began with a thorough review of existing hospital policies, infection control protocols, and environmental safety guidelines. Stakeholders from multiple departments including Environmental Health and Safety, Facilities Management, Employee Health and Campus police were consulted in the policy development process. A needs assessment was followed to identify gaps and areas requiring improvement. The policy was designed using key resources, including the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the National Emerging Special Pathogens Training and Education Center (NETEC). A framework based on the CDC’s “Identify, Inform, and Isolate” model was employed, with tailored procedures addressing both clinical and operational aspects of preparedness and response. Results: The final policy grouped HCIDs into five categories: (1) Viral Hemorrhagic Fevers (VHF), (2) Novel Respiratory Viruses, (3) Measles, (4) Bioterrorism Agents, and (5) Other Emerging Pathogens. For each category, the policy delineated specific identification criteria, isolation protocols, and management procedures. It also provided guidance on engineering controls, visitor management, patient placement, environmental cleaning, and transportation. Additionally, the policy included external resources on clinical treatments and broader infection control issues. Conclusion: The development of an HCID policy in accordance with TJC Standard IC.07.01.01 provides a robust framework for hospital preparedness in managing high-consequence infectious diseases. By collaborating with Infection Control teams, healthcare institutions can develop protocols that enable swift, effective responses to emerging pathogens, ensuring adaptability during outbreaks. This policy not only facilitates TJC compliance but also enhances hospital readiness for future infectious disease threats. Moreover, it offers a replicable model that can assist other healthcare organizations in strengthening their emergency response capabilities and maintaining survey readiness in an evolving healthcare landscape.

Background: Investigation of transmission of respiratory viruses (RV) in healthcare setting is understudied. To investigate the transmission dynamics of common healthcare-associated RV infections, we performed retrospective whole genome sequencing (WGS) surveillance of rhinovirus, influenza, human metapneumovirus (HMPV), and respiratory syncytial virus (RSV) at one children’s and two adult teaching hospitals in the Pittsburgh area. Methods: From Jan 2, 2018 to Jan 4, 2020, nasal swab specimens positive for rhinovirus, influenza, HMPV or RSV were collected from patients who had been hospitalized for ≥3 days. Specimens with qPCR Ct values ≤30, HMPV specimens were sequenced using tiled PCR amplicons regardless of their qPCR Ct value. Genomes passed WGS QC if ≥90% of the genome had ≥10× average coverage depth. High-quality genomes were assessed for genetic relatedness using ≤3 single nucleotide polymorphisms (SNPs) as a cut-off. Review of patient health records was performed on all genetically related clusters to identify common epidemiological connections. Results: We collected 436 rhinovirus (n = 291), influenza (n = 50), HMPV (n=47) and RSV (n=48) specimens from 360 patients. Of these, 55% (197/360 patients) were from the children’s hospital and 45% were from the two adult hospitals. Patients ranged in age from 14 days to 93 years old, 61% were male, and 74% were white. We sequenced 61.2% (178/291) of rhinovirus, 78% (39/50) of influenza, and 92% (44/48) of RSV specimens that met qPCR criteria. Among these, 63.5% (113/178) of rhinovirus, 87% (34/39) of influenza, and 89% (39/44) of RSV genomes passed WGS QC. Additionally, 79% (37/47) of the HMPV genomes passed WGS QC. We identified 13 genetically related clusters (n=5 rhinovirus; n=2 influenza; n=3 RSV; n=3 HMPV) containing 34 patients and ranging in size from 2-5 patients per cluster. We identified common epidemiological links between 56% (19/34) of clustered patients. Of these, 63% (12/19) of patients had a same-unit stay, 11% (2/19) shared a common provider, and 26% (5/19) had overlapping hospital stays. On average, genetically related clusters spanned a duration of 17 days (range: 0−55 days). Conclusion: WGS offered valuable insights into RV transmission dynamics in hospitals, which until now have not been rigorously studied. While healthcare-associated RV transmission is common, absence of epidemiological links in 44% of genetically-related cases and the distribution of cluster durations, given the incubation period, highlights the complex transmission dynamics.

Background: Adverse perioperative outcomes remain a major public health challenge despite being largely preventable. Surgical site infection (SSI) is a common preventable healthcare-associated infection (HAI) following surgery. The Barnes-Jewish Hospital anesthesiology department developed an innovative telemedicine model, the Anesthesia Control Tower (ACT), to improve intraoperative care delivery and address predisposing factors for adverse outcomes. The ACT is staffed by anesthesiologists and certified nurse anesthetists who use a customized, electronic monitoring system, bolstered with machine-learning forecasting, to provide real-time clinical decision support to anesthesia providers in the operating room (OR). In the ACT randomized control trial, alerts are generated during surgical procedures and ORs are randomized to receive ACT input based on alerts or not. We were interested in determining the effect of the ACT on infectious outcomes. Methods: We used the existing ACT study design, a randomized control trial, to determine the impact of the ACT monitoring system above on SSI, CLABSI and CAUTI. HAI surveillance was performed by IP specialists using CDC NHSN definitions for SSI, CLABSI and CAUTI. We included CABG, colon, abdominal hysterectomy, hip, and knee arthroplasty procedures performed during ACT hours of operation from July 1, 2018 to January 31, 2023 and compared outcomes among patients by randomization to receive ACT. Here, we report on the intention-to-treat analysis based on randomization status. Results: The final cohort included 8,993 procedure dates including 862 CABG procedures, 2,654 colon surgeries, 2,732 abdominal hysterectomies, 2,105 hip arthroplasties, and 833 knee arthroplasties. Baseline characteristics (e.g. age, comorbidities, wound class) were balanced by randomization status. Characteristics captured during the procedure (e.g., temperature, oxygen) were also similar by randomization status. The infectious outcomes revealed that there was no difference in likelihood of SSI (4.0% vs 4.0%), 60-day CLABSI (0.2% vs 0.3%), or 60-day CAUTI (0.0% vs 0.1%) whether the procedure was randomized to receive ACT input or not. Thirty-day mortality (2.0% vs 1.9%) and readmission (16.6% vs 15.9%) did not differ by randomization. Conclusions: In this intention-to-treat analysis of the impact of a novel anesthesiology monitoring system on HAI outcomes, we did not find a difference in the incidence of SSI, CLABSI or CAUTI. Next, we will analyze the study data in a per-protocol fashion. This RCT was conducted in a resource-rich environment with robustly implemented best practice where a second layer of anesthesiology supervision may confer little benefit. The concept of an ACT may still be helpful in resource-limited settings.

Background: The COVID-19 pandemic highlighted health inequities with rates of illness and outcomes among various populations. This project evaluates factors involved with health disparities in patients with identified hospital-associated infections (HAIs). Identifying and targeting these inequities as risk factors could reduce HAIs in affected groups. Method: We examined HAIs reported to National Health and Safety Network (NHSN) from a large integrated health network, including 21 acute care hospitals in Northern California. This data set included Methicillin-resistant Staphylococcus aureus (MRSA), Clostridioides difficile infection (CDI), and Vancomycin-resistant enterococci (VRE) infections, catheter-associated urinary tract infections (CAUTI), central line associated bloodstream infections (CLABSI), and surgical site infections (SSI) from 29 procedures. The analysis included 6,813 reported cases of HAI from 2019 to 2023. Data was stratified with equity, inclusion, and diversity risk factors, and employing multivariate regression analysis to calculate odds ratios for infection. Result: Spanish-speaking patients had increased odds ratios for CLABSI (1.8, p=0.003), CAUTI (2.08, p=<0.0001). Conclusions: The study identifies those with Spanish as preferred language, using interpreters, or family or friends as interpreters, as all having a higher risk for acquiring an HAI. These differences remain after accounting for known risk factors of age, gender, body max index (BMI), length of stay, emergency admissions, and comorbidity risk. This suggest that including and analyzing health inequity risk factors may help in early intervention to reduce or prevent HAIs.

Background: Carbapenemase-producing Enterobacterales (CPE) poses a major infection control challenge in healthcare settings. Over the past decade, Klebsiella pneumonia carbapenemase (KPC)-CPE colonization at our hospital declined to under 10% of all CPE rectal screens, while New Delhi metallo-beta lactamase (NDM)-CPE and oxacillinase (OXA)-CPE colonization rates have tripled, Figure 1. Methods: A comparative historical study was conducted on adult patients colonized with OXA-CPE (2017-2023), NDM-CPE (2017-2023), or KPC-CPE (2017-2018). Patients were retrospectively identified through the microbiology laboratory, their files reviewed for demographics, clinical characteristics, and outcomes. Results: The study included all 341 patients who underwent a screening rectal swab for CPE on admission or during contact tracing: 115 tested positive for OXA-CPE, 136 for NDM-CPE, and 92 for KPC-CPE. Patients colonized with OXA-CPE or NDM-CPE were younger (61.7±20 and 60.7±19.56, respectively) compared to those colonized with KPC-CPE (67.2±18.78; P=0.043 and P=0.013). Clinical characteristics and outcomes for the three cohorts are summarized in Table 1. Patients colonized with OXA-CPE or NDM-CPE were more likely to be admitted to surgical wards, have fewer urinary catheters and decubitus ulcers, and were more often discharged home compared to KPC-CPE colonized patients. OXA-CPE and NDM-CPE genes were predominately associated with Escherichia coli, while KPC-CPE gene was mainly found with Klebsiella sp. Conclusions: OXA-CPE and NDM-CPE colonized patients are younger, less debilitated and primarily reside at home. These findings prompted a revised CPE admission strategy, resulting in higher detection of OXA-CPE and NDM-CPE colonization upon admission.

Background: Candida auris, a multi-drug resistant fungal pathogen, was first detected in Tennessee healthcare facilities in 2022. C. auris can colonize a patient’s skin and cause clinical infection. Patients with clinical infections have high mortality, with a wide range of reported rates between 30 – 72%. Here we compare the risk factors associated with 30-day all-cause mortality among colonized and clinical cases in Tennessee. Method: Clinical and colonization C. auris case data was obtained from the Tennessee State Public Health Laboratory. Cases with only a skin specimen were classified as colonization, while patients with any other sterile or non-sterile collection site were classified as clinical. Mortality data was obtained through the Tennessee Office of Vital Records and matched with C. auris case information. Risk factors for multi-drug resistant organism acquisition were collected using a REDCap survey completed by facility staff. Chi-square tests were used to compare mortality and risk factor differences. All analyses were conducted in SAS Enterprise Guide v8.3. Result: Between 2022 and 2023, 130 out of 418 colonized patients (31.1%) and 33 out of 108 clinical cases (30.1%) died with no significant differences in age. Of the patients that died, 20 (60.6%) with clinical infection and 50 (38.5%) with colonization died within 30 days of specimen collection (p<.05). However, eight patients with clinical infection who died within 30 days of specimen collection were previously colonized. Risk factors associated with C. auris acquisition were available for 55 patients with clinical infection and 120 with colonization. Patients with clinical infection who died within 30 days of specimen collection were more likely to have incontinent urine (p<.05), a draining wound (p<.05), and have a gastric tube placed (p<.05) than those who survived. Patients with colonization who died within 30 days of specimen collection were more likely to have a previous stay in an inpatient rehabilitation facility (p<.01), an ambulatory surgery center (p<.01), and less likely to have a tracheostomy tube placed (p<.05) than those who survived. Conclusion: Patients with clinical C. auris infection are more likely to die within 30 days of specimen collection than patients with colonization in Tennessee. However, risk factors associated with C. auris acquisition varied between patients with clinical infection or colonization and are not consistently associated with higher mortality. Clinical teams should emphasize infection prevention and control practices that reduce the risk of invasive infection in colonized patients in all settings, regardless of perceived risk.

Background: SSI results in increased mortality, morbidity, length of stay and healthcare costs. Use of nasal iodine for some surgeries has been proposed as an easy, economic alternative to 5-day preoperative chlorhexidine bath and intranasal mupirocin decolonization in SSI prevention but data on effectiveness is limited. We aim to assess the association between preoperative nasal iodine application and odds of SSI. Methods: We performed a retrospective study of all total hip replacement, total knee replacement, and spinal fusion surgeries performed between January 2023 through June 2024 in 10 facilities in a large healthcare system. Demographics, clinical risk factors, and procedural data were collated from the electronic health record and merged with SSI data obtained through routine surveillance by trained infection preventionists using standard NHSN (National Healthcare and Safety Network) definitions. Patients with SSI present at the time of surgery were excluded. Nasal iodine compliance was defined as documentation of nasal iodine administration in both nostrils on the day of surgery in the preoperative space. Surgeries where nasal iodine was documented as not given or that had absence of documentation were counted as noncompliant. Descriptive statistics were used to compare compliant and noncompliant patients. Multivariate logistic regression was performed to assess the association between nasal iodine compliance and SSI. Results: A total of 14,505 surgeries were included, of which 161 (1.1%) were complicated by SSI. 12,281 (84.6%) of patients were compliant with nasal iodine. Around 55% of the noncompliant surgeries had absent documentation. In the univariate analysis, compliance was associated with several clinical and procedural factors including older median age, female gender, White race, shorter procedure duration, elective procedure, outpatient procedure, and lower ASA score. Unadjusted SSI rate per 100 procedures was lower in those compliant with nasal iodine compared to noncompliant (1% and 1.6% respectively, p=0.01). (Table 1) After adjusting for age, gender, race, procedure type, and procedure duration, there was no significant difference in odds of SSI associated with nasal iodine compliance. (Odds ratio 0.78, p=0.23) (Table 2) Conclusion: Use of nasal iodine on day of surgery did not impact odds of SSI after adjusting for other clinical factors. This study is limited by inclusion of cases with absent documentation of nasal iodine and differences in clinical and procedural characteristics between compliant and noncompliant patients. Further studies are needed to assess effect of nasal iodine on SSI.

What is lost if we don’t have a diagnosis? This article examines the aims of clinical medicine and the role of understanding in these aims. Starting from a case prompt with a patient suffering from persistent physical symptoms, I argue that understanding is at the clinical core and that the target of such understanding is the patient’s body with symptoms. Synthesizing accounts of medical understanding and phenomenology of illness, I suggest that the understanding sought in the clinic extends beyond mechanistic explanation to include a sense of bodily intelligibility and that diagnoses are useful but not necessary tools to this end.

Background: Catheter-related or central line-associated bloodstream infection (CRBSI/CLABSI) is a common and serious complication in patients undergoing hemodialysis (HD), often resulting in significant morbidity and mortality. Managing CRBSI/CLABSI often requires removing the central venous catheter (CVC) and placing a new one at a different vascular site. However, this approach is not always feasible for these patients that often have limited vascular access. No adjunct antimicrobial lock therapy has been FDA-approved for managing such infections and is urgently needed to salvage HD vascular access. Our study evaluated a novel triple combination antimicrobial catheter lock solution containing minocycline, EDTA, and ethanol (Mino Lok (MLT)). MLT has shown broad-spectrum in-vitro activity and positive results in a Phase 2 trial. Herein, we report the results of MLT CVC-salvage therapy in the subgroup of HD subjects from a phase 3 trial. Methods: This international, multicenter, superiority trial was conducted at 34 sites. HD, cancer, or other patients requiring a long-term CVC (LTCVC), aged ≥ 12 years, with CLABSI/CRBSI, were enrolled and randomized (1:1 ratio) to receive MLT or site-specific standard of care (SOC) antimicrobial lock therapy for 2 hours/day for 7 days. The primary endpoint was median time to catheter failure (i.e., mortality, catheter removal due to inability to administer lock or infectious-related reasons, worsening signs/symptoms, persistent or recurrent bloodstream infection, or deep-seated infection). Results: From February 2018 to February 2024, 54 HD patients were enrolled and randomized: 26 to MLT and 28 to SOC. Gram-negative bacteria accounted for 50% of CLABSI/CRBSIs, gram-positive bacteria 43%, and Candida species 7%. Highly virulent organisms (non-commensals) caused 69% of all cases. Patients in SOC had a significantly shorter time to catheter failure compared to MLT (p=0.03) with 25% of CVCs failing by day 6 and 50% by day 22 in SOC compared to 25% failing by day 37 in MLT (Figure 1). Similarly, 16 subjects (57%) in SOC had a CVC failure event compared to only 8 (31%) in MLT. Adverse events (AEs) and serious AEs (SAEs) were comparable between the two groups. There were no drug-related SAEs. Conclusion: This phase 3 pivotal study demonstrated MLT to be highly effective and superior to SOC antimicrobial lock therapy in salvaging LTCVCs associated with CRBSI/CLABSI in HD patients. MLT has broad-spectrum activity, was well-tolerated, and was not associated with drug-related SAEs. MLT may satisfy an urgent unmet need in salvaging HD catheters in patients with CRBSIs/CLABSIs.

Background: Urinalysis with reflex culture order sets (reflex order set) require urinalyses to meet specific criteria before triggering a culture to reduce unnecessary urine cultures and inappropriate treatment of asymptomatic bacteriuria (ASB). A reflex order set was designed and implemented at a large academic medical center in 2016 and updated in June 2022 to require clinicians to select which pre-specified exemption the patient met to bypass the reflex order set and order a urine culture. We aimed to assess the association between reflex order set bypass and antibiotic prescribing for urinary tract infections (UTIs) in outpatient encounters. Methods: Patient demographics, co-morbidities, encounter diagnoses, and treatment data, including required antibiotic indications, were extracted from all outpatient healthcare system adult and pediatric patient encounters utilizing the reflex order set. Using multivariable logistic aggression, we assessed associated odds with 95% confidence intervals (95% CI) of bypassing the reflex order set and antibiotic prescribing for UTI. Results: From June 2022 to June 2024, 192,310 encounters met inclusion criteria. After adjusting for patient factors, bypassing the reflex order set was associated with higher odds (2.87 95% CI: 2.81 to 2.94) of antibiotic prescribing for UTI. Increasing age, female gender, indwelling catheter, history of urological surgery, UTI, and neurogenic bladder were associated with increased prescribing. Being on immunosuppression, pregnancy, pending urological surgery, renal transplant status and chronic kidney disease were associated with reduced odds of antibiotic prescribing (Table 1). Discussion: Urinalysis reflex order set implementation in a large ambulatory clinic system was associated with lower likelihood of antibiotic prescribing for UTI. Further analysis will evaluate accuracy of selected bypass indications and appropriateness of antibiotic prescriptions to identify opportunities for optimizing this intervention.

Background: Bacteremia is associated with significant morbidity and mortality. At least 14 days of antibiotic treatment has traditionally been the standard of care. However, shortening the duration of antibiotic therapy is a key strategy for improving antimicrobial stewardship. This meta-analysis of randomized controlled trials (RCTs), including the recently published BALANCE trial, seeks to identify the duration of antibiotics needed to optimize this mortality benefit by comparing seven versus 14 days of antibiotic duration. Hypothesis: The mortality risk ratio (RR) in the 7-day group is similar to 14-day group. Methods: Multiple electronic databases and trial registries were searched on December 29, 2024, for RCTs reporting mortality outcomes in patients with bacteremia treated for seven versus 14 days of antibiotics. We estimated the effect of these two-treatment durations using random-effects meta-analyses with the generic inverse variance method. Subgroup analyses were conducted to assess the impact of the source of bacteremia on mortality. Results: Four eligible RCTs consisting of 4,794 patients with bacteremia, were included. Median age was 71 years (interquartile range (IQR): 69-73), and 47% (IQR: 45%-49%) were male. Of the patients with bacteremia, 87% had gram-negative bacteria and 13% gram-positive bacteria. Patients with Staphylococcus aureus bacteremia, severe immune compromise, prosthetic heart valves, syndromes with well-defined requirement for prolonged treatment such as infective endocarditis or osteomyelitis, single positive blood culture with common contaminant, Candida or other fungi were excluded. Overall mortality rate was 8%. The RR for 90-day and 30-day mortality between 7 versus 14 days was 0.92 (95% CI: 0.79 – 1.06) and 0.92 (95% CI: 0.96-1.12), respectively. Median antibiotic-free days were higher in the 7-day group than 14- day group (19 days vs 14 days, p=0.03). The rates of Clostridioides difficile infection were similar in two groups (1.6% vs 1.5%, p=0.97). Subgroup analysis indicated no effect modification by the source of bacteremia. The risk of bias was assessed as low. Conclusions: This systematic review and meta-analysis of RCTs found no difference in mortality between 7- and 14-day treatment durations in low-risk patients with non-Staphylococcus aureus bacteremia. Reducing antibiotic treatment for uncomplicated gram-negative and gram-positive bacteremia to 7 days is a critical antibiotic stewardship intervention.

Background: The Texas Epidemic Public Health Institute (TEPHI) aims to safeguard public health and bolster the economy by preparing for infectious disease outbreaks. The Infection Prevention and Control Webinar (IPC) 200 series of the Small Rural Healthcare Preparedness offers free educational resources and continuing education for public health and healthcare personnel responsible for infection prevention programs across ten lectures from requested topics from TEPHIs IPC 100 series. Methods: Data from the second year of the Infection Prevention and Control lecture series were collected using attendee registration and attendance data, knowledge assessments, and post-lecture evaluation surveys via WebEx®, QuestionPro®, and Microsoft Teams®. The modules were developed using resources from the Association for Professionals in Infection Control and Epidemiology (APIC), the Occupational Safety and Health Administration (OSHA), the Centers for Disease Control and Prevention (CDC), The Joint Commission (TJC), and Centers for Medicare and Medicaid Services. Results: The series had 1,088 attendees to the live lectures and generated 3,103 YouTube views. Lectures were accredited for 1.0 hours of public health education and a-IPC certification, with 8 of 10 sessions offering 1.0 continuing education hours for CIC certifications for infection preventionists. Of the 286 participants completing knowledge assessments, the average score was 91% (range: 81% in Module 201 to 96% in Module 206). Post-evaluations (n=280) rated the content highly (mean: 4.83/5) for beneficial, easy to understand, and clear/concise. Additionally, 90.4% of respondents indicated plans to implement the knowledge gained, and 98.9% expressed interest in attending future sessions. Conclusion: The Infection Control lecture series improved participants’ knowledge of infection prevention and control best practices. By disseminating evidence-based education and providing no-cost continuing education, the series equips healthcare personnel with the tools to foster safer environments for patients and staff in healthcare settings.

Background: Uganda has a high prevalence of healthcare associated infections (HCAIs) with 28% often linked to inadequate hand hygiene practices among health workers. Hand hygiene is one of the most important measures in reducing the transmission of nosocomial infections. Implementing a world health organization (WHO) multimodal hand hygiene improvement strategy has shown influence on health workers’ behaviors, knowledge and practices. We aimed at evaluating hand hygiene compliance among health workers before and after implementation of the WHO multimodal improvement strategy at select health facilities(HF) in Uganda. Method: 27 health facilities were randomly selected from two regions in Uganda to implement the WHO multimodal hand hygiene improvement strategy over a period of 4 weeks. Before the interventions, healthcare worker’ (HCW) compliance with hand hygiene during routine patient care was directly observed using the WHO hand hygiene observation tool. Interventions included; weekly onsite mentorships focusing on Training and education, provision of locally produced alcohol-based hand rubs (ABHR), soap, and placement of reminders such as posters at point of care areas to emphasize the importance of hand hygiene. HCWs from different facility departments were designated to champion hand hygiene. We recorded and distributed hand hygiene promotional videos to the health facilities to reinforce key messages consistently. After the interventions, follow up observations were conducted and data was analyzed using SPSS 20. Results: A total of 156 health workers were observed at baseline and 151 at follow on. 1,205 hand hygiene opportunities were recorded at baseline and 1,369 at follow on. 454 actions were observed at baseline and 845 after. Healthcare worker hand hygiene compliance improved from 32.6% (SD=23) to 60.7% (SD=23; p=0.0083) after the intervention. The increase in compliance to hand hygiene was different across all professional categories with significant improvement among Lab technicians (72% Versus 35%). Compliance among students remained low at 36% versus 38% post intervention. 76% of the observed health workers preferred use of locally produced ABHR while 22% used water and soap. Conclusion: The improvement in hand hygiene compliance among health workers following short term interventions using the WHO multimodal improvement strategy shows potential effectiveness. This underscores the importance of prolonged commitment from hospitals in adopting and reinforcing this strategy for long-term improvements in hand hygiene practices among health workers.

Background: Ventilator-associated pneumonia (VAP) primarily occurs due to the aspiration of secretions containing microorganisms from the oropharynx or stomach into the lungs. Preventing aspiration is a critical strategy for reducing VAP incidence. This study analyzed the impact of aspiration prevention measures—head-of-bed elevation (HOBE) and enhanced oral care—on VAP rates in adult intensive care units (ICUs). Method: This interventional study was conducted in the adult ICU of a 2,734-bed tertiary care hospital. A total of 8 ICUs (medical, surgical, cardiology, cardiovascular, neurology and neurosurgery) with 112 beds observed an increase in VAP incidence from January to April 2023, prompting enhanced measures in May 2023. The first intervention involved revising and reinforcing indications for head-of-bed elevation (HOBE) while strengthening monitoring and on-site feedback. During clinical procedures such as positional changes requiring a supine position, oropharyngeal suctioning was performed before lowering the head of the bed, and staff were trained to ensure prompt restoration of the HOBE to the appropriate position afterward. The second intervention improved oral care by replacing chlorhexidine and gauze with tooth brushing. A protocol was developed requiring 2 minutes of brushing teeth, artificial airways, tongue, and palate using a silicone toothbrush moistened with saline or sterile water, excluding patients with contraindications such as bleeding risks. Monitoring revealed missed areas during brushing, necessitating additional simulation training using dental models and colored toothpaste to confirm plaque removal. The pre-intervention period was conducted over 9 months (August 2022 to April 2023), while the intervention period lasted 17 months (July 2023 to November 2024). VAP incidence rates were compared before and after the intervention. Additionally, the incidence of VAP associated with pathogens such as Klebsiella pneumoniae, Acinetobacter baumannii, or Pseudomonas aeruginosa, often isolated from dental plaques of ICU patients, were analyzed. Results: The incidence rate of VAP per 1,000 ventilator days among adult ICU patients decreased from 3.9 (66/16,849) before the intervention to 2.4 (78/32,185) after the intervention (IRR, 0.62, 95% CI, 0.45-0.86; P = 0.007). Similarly, the incidence rate of VAP associated with pathogens K. pneumoniae, A. baumannii, or P. aeruginosa were 1.6 (27/16,849) before the intervention, and 1.0 (31/32,185) after the intervention (IRR, 0.60, 95% CI, 0.36-1.01; P = 0.07). Conclusion: As a result of implementing enhanced head-of-bed elevation and oral care protocols for ventilated patients in the adult ICU, the incidence of VAP significantly decreased. Further multicenter studies are needed to validate our findings.