Background: Immunocompromised patients are at an increased risk of infections. With the introduction of the new Hospital Onset Bacteremia and Fungemia (HOB) quality metric, it remains uncertain whether the incidence would be higher within these vulnerable populations. Additionally, the rate of antimicrobial resistance (AMR), which complicates the infection management, is not completely understood. We aim to provide insights into the incidence of HOB in cancer, transplant and surgical patients as well as challenges posed by AMR. Method: Data from three multi-center retrospective studies are included: 1. Adult patients in 38 US hospitals between October 2015 and June 2019 with a procedure under the National Healthcare Safety Network (NHSN) surveillance for SSI to assess the incidence of SSI and SSI-HOB co-occurrence; 2. Adult patients in 41 US hospitals between October 2015 and June 2019 with DRG for myeloproliferative (MP) cancer, solid tumor cancer, transplant, and non-cancer/non-transplant (“reference group”) to quantify their association with HOB; 3. Evaluation of adult patients in 168 hospitals between April 2018 and December 2022 to assess the rate of AMR pathogens and the proportion of AMR among bacterial isolates in patients with and without cancer. Results: 1.Rate of hospital-reported SSI was 0.15 per 100 admissions and admissions with SSI had significantly higher incremental cost ($30,689) and length of stay (LOS) (11.6 days); further, the incidence of HOB was 6-fold higher in admissions with SSI and SSI admissions with HOB resulted in additional $24,586 to cost of care and 6.3 days to the LOS; 2. Rate of HOB in MP cancer was 2-7-fold higher and 57% to 4-fold higher in transplant patients compared to the reference group, depending on LOS. There were no statistically significant differences in the risk of HOB between solid tumor cancer and the reference; 3. AMR pathogen rates were higher in cancer patients than patients without cancer for most pathogen groups, including vancomycin-resistant enterococci (IRR 1.95), extended-spectrum beta-lactamase (ESBL) producers (IRR, 1.48), carbapenem-nonsusceptible Enterobacterales (IRR, 1.46) and multidrug-resistant Pseudomonas aeruginosa (IRR, 1.31). The percentage of nonsusceptible isolates in most pathogen groups was lower in patients with cancer versus without cancer except for ESBL producers among Enterobacterales and vancomycin resistance among enterococci, which were higher in cancer patients. Conclusion: Certain vulnerable patient populations were found to be at greater risk of HOB including those with SSI, MP cancer and transplant patients. The higher incidence of AMR in cancer patients further complicates management of high-risk infections.

Background: Procedures performed at Ambulatory Surgical Centers (ASCs) have been increasing in type and volume for over a decade. Similarly, outbreaks in ASCs are increasingly detected, but ASCs face unique challenges to Infection Prevention and Control (IPC). In 2023, Tennessee state and local health departments (HDs) responded to an outbreak of 14 Nontuberculous mycobacteria (NTM) periprosthetic joint infections in an ASC, unveiling gaps in IPC practice and significant barriers to resolving them. Method: Cases were detected through third-party clinical laboratory reporting. HD Infection Preventionists (IPs) conducted on-site infection control assessments using qualitative observation, verbal interview, and CDC’s Infection Control Assessment and Response (ICAR) and Association of perioOperative Registered Nurses (AORN) checklist tools. A citizen complaint triggered an independent survey performed by the state’s regulatory body. Result: ICAR revealed there was no Water Management Plan (WMP) for the building or ASC suite. Areas with lapses in IPC practice included aseptic technique, instrument handling, and environmental services (EVS). There was no surveillance mechanism for tracking surgical site infections. Complications were tracked via paper provider surveys but could not be produced when requested. Regulatory survey identified additional violations related to biohazardous waste and unlicensed performing of pediatric procedures.

The facility IP and the sterile processing department lacked specialized training in their respective areas. The IP had no knowledge of reportable disease requirements. The outbreak was reported by the clinical laboratory only after five cases had been detected at a separate facility where revisions were performed. Conclusion: Major barriers to IPC best practice included lack of subject matter expertise and the complexity of multi-stakeholder ownership and operation. A healthcare management corporation holding the facility license was responsible for ASC operations, employment of non-physician staff, and adherence to state and federal regulations. An independent orthopedic group employed surgeons, and a third healthcare system owned the building and contracted EVS. As a result, the licensee was not capable of addressing building water management, and the facility IP had no authority over EVS or the physicians’ group to require complications reporting. Public health action was delayed by the ASC not reporting the outbreak, despite NTM being reportable in Tennessee. This delay was likely due to lack of knowledge around reportable diseases and poor surveillance and follow-up. Once all stakeholders met, compliance with recommended interventions improved. Public health authorities should consider supporting ASC IP education opportunities, engaging varied stakeholders during outbreaks, and enhancing surveillance within this setting.

Background: Seasonal viral respiratory pathogens present a significant clinical burden to pediatric patients. During the viral season, hospitals face an increased number of patients requiring isolation precautions. In surveying isolation practices among pediatric institutions, we identified a high variation in interpreting and implementing isolation precautions, including the duration of isolation. This variability resulted in practice challenges articulated by Infection Prevention and Control (IPC) and clinical teams. We sought to simplify and reduce wasteful work processes. Through the initial phase of this quality improvement project, we examined the congruency between isolation orders and signage and the IPC surveillance time needed to modify isolation practices. Method: Our interdisciplinary team developed and created a process map of isolation work processes, identifying at least 7 decision points to place isolation or to de-isolate hospitalized patients. A prioritization matrix was used to select drivers for maximum impact: 1) initiate empiric isolation for the most common viral respiratory pathogens and 2) develop and implement a tool for de-isolation. Improvement measures included isolation order and signage appropriateness (outcome), modifications of isolation orders by providers (process), and IPC time for correcting isolation or providing just-in-time training during rounds (balancing). Both outcome and balancing measures were captured using an investigator-developed survey, which was streamlined 3 times. Comprised of 25 questions, the survey is completed throughout the month by IPC during surveillance and environmental rounds, with collection spanning 2 viral seasons. Descriptive statistics are used to analyze the data for trending and practice modifications. Result: We completed 929 individual observations via survey over 8 months. The appropriateness of isolation precautions orders improved over time, with a shift in the center line (Figure 1). We identified that the rate of appropriateness decreased at the height of the viral respiratory season due to additional precautions (droplet isolation for certain viruses based on the risk of splashes or sprays per our policies). Surveillance time for correcting precaution signs and/or orders decreased from ≥ 15 to ≤ 5 minutes (Figure 2). Conclusion: Automation and use of empiric isolation precautions orders for the most common viral respiratory pathogens in our hospitalized patients has led to a reduction in wasteful workflow processes, minimized decision points, and has decreased IPC time spent correcting isolation orders and signs. In the project’s next phase, we hope to minimize patients’ time in isolation by using a nurse-driven tool to assess their clinical readiness for de-escalation of isolation during their hospitalization.

Background: Hospital outbreak detection depends on microbial cultures that cluster in time and space, generally defined as inpatient units. Data are lacking on whether Emergency Departments (EDs) may be a source of transmission. Objective: Assess ED exposure as a source of transmission using routine whole-genome sequencing (WGS) of bacteria from ED and inpatient specimens in a tertiary academic medical center. Methods: We performed a prospective cohort study of patients at a 450-bed academic medical center who had bacteria isolated from ED and inpatient specimens between April 1, 2022 and March 31, 2023. Each organism per patient specimen was routinely sent for WGS and genomic clusters were identified as two or more bacterial isolates cultured from different patients which were genomically related by WGS, generally, 25 or fewer single nucleotide polymorphisms apart. Retrospective chart review using a standardized assessment form was conducted for patients involved in hospital-onset genomic clusters to assess for epidemiologic links occurring in the ED versus other hospital areas (inpatient or outpatient). Results: During a 1-year period, 3614 isolates were sent for WGS with 44 genomic clusters identified. Thirty (68%) clusters were excluded because they consisted of community-onset cases, suggesting either transmission outside of our hospital or acquisition of a common community strain. Fourteen hospital-onset clusters were evaluated for possible ED transmission. Of the 14 clusters, median cluster size was 2 patients (range: 2-5). Most common pathogens were Enterococcus faecalis (N=4), Pseudomonas aeruginosa (N=3), and Staphylococcus aureus (N=2), with more Gram-positive (N=8) than Gram-negative (N=6) clusters. Nine (64%) clusters had evidence for ED transmission, which were categorized as probable (ED as sole opportunity for exposure, N=5), or possible (ED among multiple healthcare opportunities for exposure, N=4). Examples of ED exposures included (non-mutually exclusive): same ED unit (N=9, 100%), proximal time in ED (≤5 days apart), (N=6, 67%), common ED staff (N=5, 56%). Without WGS, identification of the ED as the probable source of transmission was hampered by the fact that 99% of cultures were taken on different units, with a median time between ED exposure and positive culture of 9 days (range: 0-163). Conclusions: Routine WGS of bacterial isolates in a 450-bed tertiary care center identified 14 hospital-associated transmission events in a year, two-thirds of which were probably or possibly associated with the ED. ED transmission is common but difficult to identify because infection prevention processes rely on positive cultures collected in the same unit close in time.

Background: Pediatric patients with underlying malignancies and hematological disorders, especially those undergoing hematopoietic cellular therapy (HCT) are at increased risk of developing central line-associated bloodstream infections (CLABSI). Despite the long-standing efforts to reduce CLABSI rates, healthcare disparities, particularly in minority populations, continue to contribute to preventable harm. The role of language barriers in CLABSI risk has not been well-explored, especially in pediatric HCT populations. This study aimed to evaluate the association between limited English proficiency (LEP) and CLABSI risk in pediatric HCT patients. Methods: This retrospective cohort study analyzed patients admitted to the transplant and cellular therapy unit of a pediatric oncology center between January 2021 and June 2024. Data collected from the electronic health records included patient demographics, preferred language, underlying primary diagnosis, types and dates of cellular therapy, and central line days (CLD) in the transplant unit. CLABSI events were identified through the hospital infection prevention and control surveillance database and classified as mucosal barrier injury laboratory confirmed bloodstream infection (MBI-LCBI) or non-MBI CLABSI based on NHSN definitions. CLABSI rates were calculated as events per 1,000 inpatient CLD and were compared between patients with LEP (defined as preferred language other than English) and those proficient in English. Multivariate regression model was used to evaluate the independent risk factors for CLABSI. Results: During the study period, 280 patients contributed a total of 12,325 CLD and 93 CLABSI events; of these 57 patients with LEP contributed 3,113 CLD and 29 CLABSI. The crude CLABSI rate in patients with LEP was significantly higher (9.32/1000 CLD) than that in English proficient patients (6.95/1000 CLD) Conclusions: This study highlights the increased risk of CLABSI in pediatric HCT patients with language barriers, the risk of which likely extends beyond this patient group. Addressing these barriers through novel equitable strategies, such as language support services and culturally competent care, is crucial for reducing healthcare disparities, improving clinical outcomes and promoting a more inclusive healthcare environment for diverse patient groups.

Background: The National Healthcare Safety Network (NHSN) Antibiotic Use (AU) Option aids hospital antimicrobial stewardship programs (ASPs) by facilitating tracking and reporting of AU data. In 2021, the Tennessee Department of Health (TDH) launched an AU data quality project to improve reporting accuracy. Quarterly reports are generated, assessing data across 15 quality flags, such as reporting antimicrobial days when days present (DP) are zero or drug-route mismatches. Flags also highlight significant outliers, including DP or AU rates outside the median ±2 interquartile ranges compared to the prior year. Reporting facilities receive actionable solutions for flagged concerns. Method: Data from AU quality flag reports generated by the NHSN AU Option for Tennessee facilities (2021–2023) were analyzed in this cross-sectional study. The analysis summarized the frequency and distribution of flagged issues across facilities and time. Archived data were utilized, excluding updates facilities made after quarterly reports. Quarterly flags per category were calculated for each facility, with total flags compiled annually to determine category frequency and percentage. Additionally, the number of distinct facilities contributing to the annual flag count was evaluated, providing insights into data quality trends across the study period. Result: From 2021 to 2023, 97 facilities submitted data to the NHSN AU Option, resulting in 7336 flags identified in the AU quality reports (Figure 1). The most frequent flag was “location-level AU rate greater than outlying upper boundary” (n=1677, 22.9%), reported by 67 facilities and the highest reported in 2023 (n=722, 23.8%). The second was “location-level DP greater than outlying upper boundary” (n=1588, 21.6%), reported by 68 facilities and highest in 2021 (n=547, 23.5%). The most frequent non-outlier-based quality issue was “antimicrobial days reported for any drug when DP were reported as zero” (n=439, 6.0%) followed by “antimicrobial days for a single drug greater than DP” (n=48) Conclusion: The study reveals data quality concerns in AU reporting among Tennessee facilities. Flags with changes in “Location-Level Days Present” and “AU Rate” outliers being prominent across the study period. These findings underscore the need for continuous monitoring and targeted feedback to enhance data accuracy, as well as a need for antimicrobial stewardship personnel to be able to identify and address changes in prescribing patterns and patient populations efficiently within their facilities. Addressing recurring challenges identified can improve AU data reliability, supporting more effective antimicrobial stewardship and better patient care outcomes.

Background: Gram-positive bacteremia is a challenging cause of morbidity and mortality. Past publications have shown improved patient outcomes and increased adherence to recommended standards of care with infectious disease consultation (IDC) for Staphylococcus aureus bacteremia1. Enterococcus species are another common cause of gram-positive bacteremia with significant morbidity and mortality. This study aims to assess the impact of IDC on the care of patients with Enterococcal bacteremia. Methods: A retrospective chart review was performed on 227 inpatients with at least one blood culture growing an Enterococcus species between June 2022 and November 2023. Patient characteristics collected included age, Charlson Comorbidity index, presence of endocarditis, source of bacteremia, and consultation of the inpatient ID service. Outcomes assessed included in-hospital and 30-day mortality, 30-day re-admission rate, acquisition of repeat blood cultures to document clearance of bacteremia, transthoracic (TTE) and/or transesophageal echocardiography (TEE), and anti-Enterococcal antibiotic duration. Categorical variables were compared with Chi-square or Fisher’s exact tests. Continuous variables were compared with independent t-tests or Mann-Whitney U nonparametric tests. Results: Of 227 patients, 195 (85.8%) received IDC while 32 (14.2%) did not. Patients in both groups had similar Charlson comorbidity indices. 23 (11.7%) patients had Enterococcal endocarditis, all of whom received IDC (Table 1). Patients with IDC had a significantly higher rate of acquisition of clearance blood cultures (98.96% vs. 83.87%, p 76.80% vs. 56.25%, p = .014), and TEE (20.21% vs 0.0%, P = .005) (Table 2). There were no significant differences in in-hospital mortality, 30-day mortality, 30-day re-admission rate, or duration of anti-Enterococcal antibiotics. Conclusions: These results support the conclusion that patients with Enterococcal bacteremia who received IDC were more likely to be managed according to currently recommended standards of care. In this cohort, IDC did not have a statistically significant association with differences in mortality, re-admission rate, or antibiotic duration. Patients with Enterococcal bacteremia are likely to benefit from IDC, especially as they frequently have significant life-limiting co-morbidities complicating their care. References: Vogel M, Schmitz RP, Hagel S, Pletz MW, Gagelmann N, Scherag A, Schlattmann P, Brunkhorst FM. Infectious disease consultation for Staphylococcus aureus bacteremia - A systematic review and meta-analysis. J Infect. 2016 Jan;72(1):19-28. doi: 10.1016/j.jinf.2015.09.037. Epub 2015 Oct 9. PMID: 26453841.

Background: Since the intensive care unit (ICU) is a high-risk area for healthcare-associated infections, effective infection control in the ICU is crucial. Carbapenem-resistant Enterobacterales (CRE) infections have been increasing and have become a significant concern for ICU patients. While CRE colonization does not require treatment, as it represents a carrier state, early detection is crucial to minimize CRE transmission. This study aims to identify the CRE colonization rate and its risk factors in ICU patients to provide a basis for CRE infection control in the ICU. Method: This retrospective cohort study was conducted at a university hospital in Korea from July 2023 to December 2023. Adult patients aged ≥18 years who were admitted to five ICUs (i.e., surgical 1 and 2, medical, cardiopulmonary, and emergency ICUs) and underwent active surveillance cultures for CRE using rectal swabs within 2 days of admission were included. Re-admissions and patients with confirmed CRE prior to admission were excluded. General, clinical, and environmental factor data were retrospectively collected using the hospital’s electronic medical records and nursing documentation system. Multivariate logistic regression was performed on variables with p Results: Out of a total of 1,473 ICU admissions, excluding duplicate admissions, 10 patients with confirmed CRE colonization prior to ICU admission and 722 patients who did not undergo active surveillance cultures within two days of admission were excluded. Among the remaining 741 included patients, 25 (3.37%) patients were colonized with CRE. Klebsiella pneumoniae was the most frequent isolate (n=18, 72%) and 12 patients (48%) were identified as having carbapenemase-producing Enterobacterales. In the multivariate logistic regression analysis, the following were identified as independent risk factors for CRE colonization: age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.01-1.11; p=0.036), admission from other hospitals (OR, 8.77; 95% CI, 2.43-31.59; p Conclusion: Based on the results of this study, early detection of patients with CRE colonization, followed by target screening and proactive infection control measures such as preemptive isolation, could play a key role in preventing the spread of CRE in the ICU.

‘Trade wars are good, and easy to win,’ tweeted Donald Trump in 2018. The US–China trade war that followed proved otherwise – especially when confronting a major economic power. Yet, can trade wars ever be good? While the academic consensus holds they harm all participants, we argue that under certain circumstances they can produce positive outcomes. Set against the backdrop of the Liberation Day tariffs announced on April 2, 2025, this paper examines the limits of the Ricardian free trade model underpinning the current multilateral trading system, identifies when trade wars may serve strategic goals, and explores alternative rules to address state-capitalist distortions without costly, prolonged conflict.

Background: Effective integration of antimicrobial resistant organism (ARO) admission screening into clinical information systems (CIS) can facilitate prompt identification of patients at risk of an ARO and interrupt transmission. However, ARO admission screening remains suboptimal in Alberta, Canada following implementation of the ARO admission screening tool in the provincial CIS. We sought to understand the determinants of adherence with the use of the ARO admission screening tool in the CIS. Methods: A mixed-methods study was conducted using a survey, human factors observations, and qualitative focus groups. Eligible participants included nursing staff and physicians from emergency departments and inpatient units in acute care and acute rehabilitation facilities where the ARO admission screening tool was utilized in the CIS in Alberta, Canada from September 6, 2023 to June 18, 2024 (n=100). A survey (REDCap) explored staff perceptions and experiences using the tool in the CIS. Observations and interviews of nursing staff completing the tool were guided by the Systems Engineering Initiative for Patient Safety model. Virtual (Zoom) semi-structured focus groups explored barriers and enablers of using the tool guided by the Theoretical Domains Framework. Descriptive analysis of survey responses was conducted using Microsoft Excel (Version 2409). Field notes and focus group transcripts were used for a rapid qualitative, thematic analysis. A weaving narrative by theme was used to integrate survey results with findings from the observations and focus groups. Results: There were 527 survey respondents representing all 5 health zones, 5 nurses observed and 20 interviews conducted by the human factors team, and 24 participants in 6 focus groups. Focus group participants represented different sized hospitals (12-1,099 beds) with varying ARO admission adherence rates (29-83%). Three emergent themes arose: context, the ARO admission screening tool, and the individual. Contextual factors included time constraints, increasing nursing workload, competing priorities, lack of patient cooperation, and a need to increase interactions with infection prevention and control programs. Attributes of the tool impacting completion included location of the tool within the CIS, lack of prompts, and multiple sources of information required to complete the tool. At an individual level, themes arose related to experience, perceptions of ARO screening, and lack of training that influenced completion of the tool. Conclusions: Among the emergent themes, multiple determinants were identified influencing the use of the ARO admission screening tool in the provincial CIS. These findings will help inform future strategies to improve ARO admission screening and reduce ARO transmission.

Background: Burn injuries pose a significant risk for infections. Nasal decolonization with mupirocin nasal ointment (MNO) is an established method to prevent infections with Methicillin-resistant Staphylococcus aureus (MRSA). We compared the effectiveness of an alcohol-based nasal sanitizer (ABNS) to MNO against MRSA bacteremia in burn patients. Methods: This was a retrospective before/after study comparing the impact of an MNO (study arm 1; Bactroban 2%, GlaxoSmithKline, NC; application: twice daily for five days after admission) and an ABNS (study arm 2; Nozin, Bethesda, MD; application: twice daily for entire stay on Burn unit) on Healthcare Associated (HA-) MRSA bacteremia events in burn patients. The Burn unit consists of eight intensive care beds for burn care and 15 regular beds in an 885 bed, tertiary care, academic hospital. Inclusion criteria were all burn patients 18 years of age and older admitted under the burn service for more than four consecutive days. No mandatory MRSA screening was performed. Outcome measure was HA-MRSA bacteremia acquired > four days after admission. Patient characteristics included demographics, BMI, intensive care need, MRSA colonization at admission, type and degree of burn, inhalation injury, total burn surface area, Baux score, inpatient mortality, length of stay by total, burn mixed acuity and burn ICU were documented. Daily compliance with treatments was extracted from patient records (EPIC, Verona, WI). Continuous patient characteristics were compared using t-tests or Wilcoxon signed-rank test (for factors with skewed distributions), and chi-square tests for categorical factors. Product-limit time-to-event analysis and log-rank test were used to compare the outcome measure between groups. Results: From 08/01/2021 to 07/31/2024 a total of 920 patients were enrolled (MNO arm: 448; ABNS arm: 462) with 239 and 217 meeting inclusion criteria. No differences in patient characteristics were detected between the two groups at all patients and >80% treatment compliance levels (MNO: 121 encounters; ABNS: 98 encounters). Patients in the MNO arm encountered 14 events compared to one event in the ABNS arm (p=0.0021). The figure displays the product-limit time to event estimates for developing HA-MRSA bacteremia at the >80% adherence level (p= 0.021). Lower adherence levels (50%, 60%, 70%) did not show significance (p>0.05) in the time-to-event analysis. Conclusion: Providing ABNS >80% of the time resulted in a significant decrease in HA-MRSA bacteremia events in burn patients compared to an MNO. The daily application throughout hospitalization may offer additional protection against MRSA in patients hospitalized for extended periods of time.

Background: Outbreaks of Zaire ebolavirus are an ongoing public health threat associated with high case fatality rates. The US Advisory Committee on Immunization Practices (ACIP) recommends preexposure vaccination with rVSV∆G-ZEBOV-GP Ebola vaccine (Brand name: Ervebo), which is effective in preventing disease caused by Zaire ebolavirus, to people at high risk for occupational exposure. We describe the perceptions and desire to be vaccinated with Ervebo among a subset of eligible US healthcare workers (HCWs). Methods: We conducted a cross-sectional online anonymous survey during March-October 2024, distributed to eligible HCWs at three Regional Emerging Special Pathogen Treatment Centers (RESPTCs): NYC Health + Hospitals/Bellevue, University of Texas Medical Branch, and Denver Health & Hospital Authority. Results: There were 66 responses (40% response rate), with the majority aged 30-49 years (63%), female (65%), and either a physician (42%) or nurse (27%). The majority (56%) had received some form of education on Ebola vaccines, most commonly through informational sheets or pamphlets (60%). Thirty-four (51%) were interested in (n=30) or already vaccinated with (n=4) Ervebo. Among those interested or already vaccinated, 44% would choose to receive the vaccine immediately, while 24% would get vaccinated if there were a case of Ebola virus disease (EVD) in the US. Among those not interested or unsure (n=32), most were concerned about risks of spreading the vaccine viral vector (44%), insufficient knowledge about the vaccine (31%), and unacceptable side effects (31%). Among all respondents, the most common concerns about adverse events included potential for a serious side effect (64%) and risk of arthritis (36%). Forty seven percent of respondents were concerned about the potential for spread of the vaccine virus vector. Respondents most frequently wanted more education on potential side effects (67%) and the risk of spreading the vaccine virus vector (59%). Among those not interested in vaccination or unsure (n=32), some may be convinced to accept vaccination if there were an EVD outbreak in the US (44%), if they better understood the risks and benefits of vaccination (34%), and if they better understood the vaccine safety (31%). Conclusion: During a period with no EVD outbreaks, a majority (51%) of eligible HCWs surveyed at three US RESPTCs were interested in or had received Ervebo. A significant proportion (24%) prefer to postpone vaccination until there is a case of EVD in the US. Deployment of Ervebo to eligible US HCWs may be optimized by addressing concerns identified in this study.

Consulting dictionaries during writing requires time and cognitive resources. ColloCaid, a writing assistance prototype freely available online, was designed to minimize the cognitive strain on writers by embedding a collocation database within the writing environment. Usability surveys have shown ColloCaid can indeed help. In this study, we go beyond user perceptions. Using authentic excerpts of student academic writing by 27 advanced L2 English speakers, we analysed (1) the lexical coverage of the tool, (2) the collocation changes prompted by the tool, (3) the reasons behind decisions to revise collocations, (4) the effect of revisions prompted by ColloCaid, and (5) the participants’ perceptions of using the tool to revise authentic writing assignments. Our findings indicate that ColloCaid offered good academic collocation coverage, that the participants tended to accept its collocation prompts with discernment, and that the revisions made resulted in more fluent texts overall.

Background: Surgical Site Infections (SSIs) are a major cause of morbidity resulting in devastating patient outcomes following an Abdominal Hysterectomy (HYST) procedure. No single intervention has demonstrated reduction in SSI rates, however, bundling prevention strategies have demonstrated reduction in SSI. In addition to our organization’s systemwide surgical site infection prevention bundle, we developed a supplemental bundle of focused strategies specific to abdominal hysterectomy procedures, to address a 37.26% increase in Abdominal Hysterectomy Standardized Infection Ratios (SIRs) in 2021. Methods: In 2021, a supplemental hysterectomy specific bundle was developed and implemented in three facilities within our health system that were experiencing increased HYST SIRs. After review of current literature, the following four strategies were included for the supplemental bundle for all abdominal hysterectomy procedures (open, laparoscopic, and robotic); the utilization of 500mg Metronidazole with Cefazolin as part of surgical antimicrobial prophylaxis, for cases where: anticipated bowel involvement occurs and for oncology patients with complex hysterectomies; the use of standardized vaginal and perineal preparation using either chlorhexidine (CHG) or Povidone Iodine (PVI); the use of a separate sterile closing tray; and changing of gown and gloves by surgical team, prior to going to abdomen from vaginal area. Compliance with the prevention strategies were measured during this period and SSI SIRs were reviewed monthly with overall trends monitored. The National Healthcare Safety Network (NHSN) criteria for SSI were used to assess for SSI after hysterectomy. Results: The SIR for HYST procedures in 2021 was 1.083 with 23 SSIs identified from 2339 abdominal hysterectomy procedures performed. Immediately following the implementation of the supplemental bundle at three facilities, the SIR decreased by 39% to 0.661 in 2022 with 11 SSIs identified from 1842 procedures performed. The HYST SIR outcomes were 0.782 in 2023 and currently at 0.979 through July 2024. Compliance during the intervention period ranged from 93.9% to 94.6%, and surgical antimicrobial prophylaxis compliance increased by 4% to 89.35% at these three facilities. Conclusion: Bundled interventions when employed, demonstrate benefit from the synergistic effects of multiple strategies decreasing the outcome rate of surgical site infections as compared to a single intervention. Establishing a standardized abdominal hysterectomy bundle, allows for minimal variation for patients undergoing abdominal hysterectomy procedures when adherence is at its maximum. Our goal is to expand systemwide based upon the successes from the three facilities, to achieve as close to zero postoperative infections by implementing evidence-based practices performed as a comprehensive bundle.

Pyotr Tchaikovsky’s early opera Oprichnik is overdue for rediscovery as one of the composer’s most overt forays into the queer themes that critics and scholars have long appreciated in his mature works. Oprichnik features the composer’s most extensive and provocative employment of travesti in its depiction of a historical figure mostly remembered for his rumoured sexual relationship with tsar Ivan IV. This paper takes a detailed look into this and other queer features of the opera within their cultural, historical and biographical contexts. These contexts, including the development of trouser roles in Russian opera, transformations in public discourse on sexuality and gender, and Tchaikovsky’s relationship with his pupil Vladimir Shilovsky, help bring into focus the special appeal the sixteenth-century Muscovy of Ivan the Terrible and his oprichniki had as a topos for a Russian artist experimenting in the artistic depiction of sexual and gender variance.

Background: Central line associated bloodstream infections (CLABSIs) are a preventable healthcare-associated infection. Evidence shows implementation of evidence-based bundled infection prevention strategies can reduce CLABSIs. We reviewed the impacts of a CLABSI prevention toolkit on CLABSI rates as well as compliance with key prevention practices. Methods: A CLABSI Prevention Bundle Toolkit was implemented in December 2023 at a quaternary care academic medical center. The toolkit delineated the elements of the bundle, including hand hygiene, daily review of line necessity, daily chlorhexidine gluconate (CHG) topical treatment, aseptic technique for insertion and maintenance, along with the responsible party for each task and educational resources for staff and patients. Additionally, the toolkit required weekly audits of CLABSI bundle by individual units and a multidisciplinary meeting to debrief each CLABSI to identify opportunities and successes. Analysis of compliance with key prevention practices, CLABSI rates and clinical details was completed before (December 2022 – November 2023) and after (December 2023 – November 2024) implantation of the toolkit. Results: Compliance with key prevention practices pre- and post-toolkit implementation is detailed in Table 1. There was a 37% reduction in CLABSI rate pre- and post-toolkit implementation as shown in Table 2. Clinical details including CLABSI classification as preventable, end-of-life or definition-based (Hsueh, Maurice and Uslan, ICHE 2022), organism, dialysis, transplant status and patient race are detailed in Table 2. Conclusions: CLABSI prevention bundles have been shown to reduce CLABSI, but implementation and compliance of the bundle can be challenging. A toolkit which outlines required tasks, responsible parties, regular audits and debriefs after CLABSI can help support healthcare teams in successful implementation of the full CLABSI bundle. Following the bundle toolkit implementation there was improvement in rates of CHG treatment and line necessity review with an overall decrease in CLABSI rates. Not all process measures included in the toolkit are able to be quantified so likely additional factors contributed to the reduction in CLABSI rates. Overall, there did not appear to be a difference in the types of CLABSIs, organisms or patient demographics in the pre and post-toolkit groups although there were more CLABSIs in transplant patients post-toolkit suggesting a complex patient population. A comprehensive toolkit can aide in implementation of a multi-faceted prevention bundle, provide a structure for accountability and help improve patient outcomes.

Background: Ventilator associated events (VAE) due to changes in positive end expiratory pressure (PEEP) or fraction of inspired oxygen (FiO2) are associated with adverse outcomes for patients in the intensive care unit (ICU). Accurately identifying VAEs is important to improve the quality of care and outcomes for ICU patients. However, we have identified “false-positive” VAEs that are triggered by stylistic manipulation in ventilator settings, or knobmanship, without “true” VAEs that are preceded by signs of hypoxia. This knobmanship creates an undue burden for Infection Preventionists to differentiate clinically relevant VAEs that impact patient outcomes from “false-positive” VAEs. Methods: We utilized the Center for Disease Control and Prevention’s National Healthcare Safety Network definition to retrospectively identify VAEs in the pre-pandemic and post-pandemic eras. Of the five ICUs monitored for VAEs, the Neurosciences ICU had the greatest number of events in 2022 and 2023. Working with the NSICU, a pilot study using an initial PEEP of 6 millimeters of mercury (mmHg) rather than 5 mmHg for all intubated patients was conducted. We hypothesized that this would reduce the incidence of “false-positive” VAE without causing adverse patient outcomes. Results: Out of 283 reported VAEs from the pre-pandemic period of January 1, 2019, to December 31, 2020, 59 (21%) were due to ventilator changes in PEEP or Fi02 without preceding hypoxia. Post-pandemic evaluation from January 1, 2022, to December 31, 2022, identified “false-positive” VAE in 56 (41%) out of 137 VAE cases. Eighty-two (59%) of the 137 VAE cases were due to changes in PEEP from 5 mmHg to 8 mmHg. After changing the starting PEEP in the NSICU to 6 mmHg from 5 mmHg, from October 1, 2024, to December 1, 2024, only 1 VAE was identified compared to an average of 10 for similar quarters in 2022 and 2023. Despite this change, no adverse events or concerns were noted by the primary ICU team or respiratory therapists. Discussion: With thoughtful changes in knobmanship we reduced the burden of “false-positive” VAE without leading to adverse patient outcomes. Conclusions: Alteration in starting PEEP can reduce the burden of VAE that are not clinically relevant and allow Infection Preventionists the opportunity to critically analyze clinically relevant VAEs to improve ICU patient outcomes.

Background: The prioritization of U.S. health care personnel (HCP) for early receipt of messenger RNA (mRNA) vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) allowed for the evaluation of the effectiveness of these vaccines in a real-world setting among a high-risk population. The purpose of this study was to summarize the sociodemographic characteristics of HCP in Oregon eligible to receive COVID-19 vaccination and estimate vaccine effectiveness (VE) of a mRNA COVID-19 vaccine booster dose. Methods: We conducted a case-control study involving HCP from 5 hospitals in Oregon. Cases were defined as those with a positive antigen test or nucleic acid amplification test (NAAT) for SARS-CoV-2. Controls were defined as those with a negative antigen test or NAAT result and were matched to cases by site and within a 2-week interval of test date. Using conditional logistic regression with adjustment for age, sex, race and ethnicity, educational level, underlying conditions, and reported exposure to COVID-19, we estimated VE for a 3rd COVID-19 vaccine booster dose (with the 3rd dose more than 150 days after the 2nd dose). VE was estimated using the screening method as 1-odds ratio x 100%. Results: Among 865 HCP, 374 (43%) were included as case-participants and 491 (57%) as control-participants. Overall, the adjusted VE of a booster dose was 62.6% (95% CI: 37.6%, 77.6%), compared to vaccination with 2 mRNA doses. Logistic regression analysis indicated that HCP with a college degree (vs. no degree, OR: 3.26, 95% CI: 1.96, 5.45), private insurance (vs. government/military, OR: 3.32, 95% CI: 1.28, 8.59), and an income level $200K+ (vs. <$50K, OR: 3.25, 95% CI: 1.60, 6.60) were more likely to have received the booster vaccine. Conclusions: The mRNA COVID-19 booster vaccines conferred approximately 63% protection against COVID-19 among Oregon HCP and were found to be effective under real-world conditions. These findings indicate moderate initial protection against SARS-CoV-2 infection and encourage remaining up-to-date with subsequent COVID-19 vaccines. The identification of sociodemographic characteristics of HCP who are more likely to have received a booster vaccine provides insight into those at higher risk for adverse COVID-19 outcomes due to lower vaccine coverage. While understanding these characteristics is valuable for directing ongoing vaccination efforts towards these populations, further research is needed to understand the mechanisms that contribute to variations in vaccine uptake.

Background: Most people in the US lack access to infectious disease (ID) expertise, with 80% of counties lacking an ID physician. This is problematic as in-person ID consultation has been shown to improve clinical outcomes such as mortality with certain invasive infections, with Staphylococcus aureus bacteremia (SAB) as the paradigm. Telemedicine consultation has emerged as a tool to expand access in rural and underserved communities though its impact on clinical outcomes is less well established. This study characterizes the impact of a Tele-ID program in improving care for patients with SAB at a network of academic-affiliated rural hospitals that do not have access to in-person ID consultation. Methods: This was a retrospective cohort study of patients with SAB who were initially evaluated at 3 academic-affiliated rural hospitals between 7/1/22 and 6/30/24. A cohort of patients who received a Tele-ID consult was compared against a cohort that did not. The primary outcome was adherence to the standard of care for SAB, defined as documentation of clearance of blood cultures, receipt of an echocardiogram, and receipt of an appropriate course of antibiotics. Secondary outcomes included clinical outcomes such as mortality and readmission rates. Results: A total of 260 discrete episodes of SAB were screened for inclusion, with 122 episodes meeting inclusion criteria. Seventy five patients (61.5%) who received a Tele-ID consult were compared against 47 patients (38.5%) who did not. Patient characteristics were overall similar in these groups, though those receiving Tele-ID consultation were more likely to have end-stage renal disease (15% vs 0%, p < .01) and indwelling hardware (56% vs 21%, p < .01). Tele-ID consultation was associated with a higher likelihood of receiving standard of care for SAB (91% vs 15%, p < .01). This finding was consistent across all hospitals and among the individual components of the primary outcome. In addition, Tele-ID consultation was associated with significantly decreased SAB-related 30-day mortality (7 vs 24%, p < .01) and SAB-related 90-day mortality (8 vs 25%, p < .01). No significant difference was observed in rates of readmission or relapsed bacteremia. Conclusion: In this retrospective cohort study of 122 patients with SAB cared for in rural, academic-affiliated hospitals, Tele-ID consultation was associated with a significantly increased likelihood of receiving standard of care and decreased mortality. This data will inform policy at regional hospitals, such as supporting a mandatory ID consult for SAB and implementation of a SAB bundle.