Specialty Infectious Disease physician.

Clinical Associate Professor University of South Dakota Medical School

Consultants for South Dakota Department of Health regarding antibiotic stewardship

Consultants West Virginia Hospital Association regarding antibiotic stewardship Background: An equitable distribution of antibiotic stewardship expertise is a challenge for rural communities across the United States. The advantage rural communities have is that there are fewer barriers for implementation of effective antibiotic stewardship strategies.

The authors worked with several rural communities in the United States over the paste several years implementing a proven antibiotic stewardship strategy that has been shown to decrease Clostridioides infection. Method: Strategy employed was avoidance of the more common microbiome damaging broad spectrum antibiotics in favor of more targeted narrow spectrum antibiotics based on local antibiogram data. Additionally, ongoing infectious disease and antibiotic stewardship access for questions as well as data review with feedback were provided.

Findings: Clostrioides infection was eliminated in some communities and others markedly decreased as shown by a very low percentage of toxin positive, PCR positive to toxin negative PCR positive isolates expected for that region. Conclusion: This strategy is translatable to other communities accompanied by antibiotic stewardship expertise and support and can be a model for community wide antibiotic stewardship which further optimizes patient and resident safety from Clostidioides infection.

Background: Adherence with antimicrobial resistant organism (ARO) admission screening is suboptimal, despite clinical support tools in clinical information systems (CIS) to facilitate the process. Behaviour change techniques to improve adherence are needed. However, in a resource-constrained healthcare system, strategies that motivate healthcare workers (HCWs) to align their practices with infection prevention and control (IPC) policies need to be prioritized. Methods: An online survey (REDCap) and a virtual (Zoom) consensus meeting using a modified nominal group technique with online voting was conducted among HCWs, IPC, and the CIS staff in September and October 2024, respectively, to achieve consensus on a prioritized list of interventions to improve ARO admission screening at acute care and acute rehabilitation facilities (n=100) in Alberta, Canada. Interventions from the Behaviour Change Wheel were mapped to barriers/enablers influencing screening adherence. Each intervention was judged across the APEASE criteria (Acceptability, Practicality, Effectiveness, Affordability, Side Effects, Equity) using a 5-point Likert Scale. Consensus to include interventions required >4 criteria with >80% agreement, consensus to exclude required >4 criteria with 80%. Interventions that did not reach consensus were discussed to determine whether to include in the final candidate list. Attendees were asked to vote on their top three interventions from the final candidate list. Results: There were 15 barriers and one enabler to ARO admission screening, mapped to 43 unique interventions. Of these, 16 interventions addressed more than one barrier/enabler, while 27 interventions only addressed a single barrier. Fifty-nine respondents completed the survey. Most respondents (63%) were IPC staff, 20% were nurses, and 17% were other HCWs (including IPC physicians). Nine interventions met criteria to include in the candidate list, 26 were excluded, and 8 interventions did not reach consensus in the survey and were discussed. There were 32 attendees at the consensus meeting (53% IPC staff and physicians, 34% clinical staff, 13% other provincial teams). Three interventions were selected: 1) creating a nursing task to complete the tool in the CIS when an admission order is signed, 2) add a banner on the CIS Storyboard when the tool is not complete, and 3) develop a best practice guideline for frontline staff on ARO admission screening. Conclusions: The survey and consensus meeting were efficient methods to determine a prioritized list of interventions, which will be implemented and evaluated, to improve ARO admission screening in Alberta.

Background: Universal decolonization using chlorhexidine gluconate (CHG) foaming soap in a hospital system has been shown to reduce healthcare-associated infections (HAIs) and colonization by multidrug-resistant organisms. Limited data exist on optimal strategies to improve compliance, and the impact of improved compliance on HAI rates. This study evaluates the effect of increasing CHG compliance on MRSA HAI rates. Methods: In 2022, our acute care VA hospital started universal CHG bathing treatment, by requiring a daily CHG bath for all patients in intensive care units and medical/surgical floors, unless contraindicated. Despite this, compliance was below goal. We performed root cause analyses to identify factors contributing to poor compliance, and then initiated a bundled intervention, including nursing staff education on the benefits of CHG bathing to reduce HAIs, how to reframe discussions with patients about refusals, removal of one alternative soap product from the inventory, and moving the CHG bathing product in clean supply rooms to be in proximity with other patient hygiene products for easier access. We evaluated the utilization of CHG bathing products through inventory data on utilization of 4 fluid ounce bottles of 4.0% weight/volume CHG solution, documentation of at least one CHG bath in the electronic medical record (EMR) per unique hospitalization, and HAI rates per National Healthcare Safety Network (NHSN) definitions for methicillin resistant Staphylococcus aureus (MRSA), before (08/2023-02/2024) and after (03/2024-12/2024) implementation of the bundle. Results: Identified barriers to CHG adherence included use of less effective alternative soap agents, perceptions of patient skin irritation from CHG, difficulty integrating CHG into existing workflows, and lack of understanding of the benefits of CHG bathing. After bundled interventions, inventory usage CHG bottles increased from 170 to 270 bottles per 1,000 bed days of care (BDOC) (p Conclusion: An intervention of staff education, removal of an alternative soap product, and improving access to CHG bathing products in supply rooms, resulted in improved CHG bathing adherence, and was associated with a reduction in MRSA HAIs in an acute care VA hospital. Interestingly, the decrease in MRSA HAIs was achieved despite an absence of complete adherence. Further data on additional strategies to improve compliance and strategies to improve healthcare worker documentation should be explored.

Background: The selection of agent for antimicrobial prophylaxis for urological procedures is guided by the results of urine cultures taken prior to the day of surgery, which can lead to variability. National society guidance recommends single-dose antimicrobial prophylaxis immediately before urologic surgery; however, significant heterogeneity remains among practicing urologists with regards to pre-treating (or post-treating) bacteriuria identified on preoperative urine culture as well as choice of antimicrobial administered. As part of an institutional quality improvement initiative, we endeavored to optimize antimicrobial selection and duration of therapy through the use of a dedicated preoperative urine culture paired with recommendations. Method: This was a single-center, prospective study of urological surgeries. A dedicated preoperative urine culture was created in partnership with our institution’s microbiology lab and antimicrobial stewardship program intended solely for the selection of preoperative prophylaxis. Antibiotic stewardship program members reviewed these urine cultures and provided recommendations to urologic surgeons. Primary outcome was postoperative infectious complication within 90 days, with sub-analyses performed for stone and prosthetic cases, which carry higher infectious complication risks. Result: The preoperative urine culture was ordered prior to 381 urology cases from 9/27/23-4/15/24. There were 41 (10.8%) infectious postoperative complications. 64/381 (16.8%) patients received pretreatment for asymptomatic bacteriuria at the surgeon’s discretion, deviating from protocol recommendations for single-dose prophylaxis. Similarly, 44/381 (11.5%) patients received postoperative antimicrobials off-protocol per surgeon discretion. There was no statistically significant difference in infectious postoperative complication rates among patients who received pretreatment (15.6%, n=10/64) versus those who did not (9.8%, n=31/317 [p=0.18]), nor in those who received postoperative antimicrobials (13.6% (n=6/44) versus not (10.4%, n=35/337 [p=0.44]). Subgroup analyses of patients with nephrolithiasis or prosthetic material showed no benefit with supplemental antimicrobials. There were 294 total days of therapy in cases with guidance-based prophylaxis (n=294), and 611 days for pre- and/or post-treated cases (n=87), representing an excess of 524 days of antimicrobial therapy. Conclusion: We implemented a specific antimicrobial stewardship initiative linking a urine culture ordering process to succinct evidence-based advice. Deviation from advice did not result in improved outcomes but did result in excess antimicrobial days. Subgroup analysis also suggested single-dose prophylaxis is appropriate for patients considered higher risk for infectious complications. These findings support the recommendation from the American Urological Association that a single dose of antimicrobial prophylaxis is sufficient for the majority of urologic cases and demonstrate a multidisciplinary approach to ability to safely implement such practice.

The field of public health is facing greater demand, significant staff turnover, and an increasing number of public health emergencies and threats. This is further compounded by an unprecedented unmet need for infection preventionists (IPs) in the workforce. The integration of infection prevention and control (IPC) material into existing public health (PH) academic programming could bridge this gap. There are very few IPC-concentrated Masters of Public Health (MPH) programs and the extent of IPC focused content in existing graduate PH programs is unknown. This project seeks to define the extent to which graduate public health courses include IPC concepts and identify potential inclusion points for these topics.

Syllabi for core PH courses were requested from all Council on Education for Public Health (CEPH) accredited graduate schools, of which there were 137 at the time of retrieval. Received syllabi (n = 245) were reviewed and coded for inclusion of IPC topics such as antibiotic resistance and antibiotic stewardship (AR) and healthcare acquired infections (HAIs). These syllabi represented 54 programs (39%) and 34 states. An additional six (6) states had no applicable programs.

Seventy-six (31%) syllabi had specific IPC content, while an additional 119 (49%) had potential inclusion points for IPC content. Seventy-two courses (30%) had neither IPC content nor potential inclusion points; these courses tended to be biostatistics, health policy and management, or environmental health classes. All analyzed MPH academic programs had at least one area within the core courses that served as a potential inclusion point for IPC content, supporting the argument that public health core competencies naturally align with IPC domains outlined in the Association for Professionals in Infection Control and Epidemiology (APIC) Infection Preventionist competency model.

Observations from this review indicate both the capability to seamlessly integrate IPC material into MPH programs and the existing deficit where this opportunity is unrealized. These findings can guide the development of tool kits to integrate the outlined inclusion points into existing graduate public health curricula guiding future workforce development to address current limitations.

This study provides the first case reported of Paraprionospio treadwelli (Hartman, 1951) in the Gulf of Mexico. Based on 242 individuals collected between 20.8 and 176 m depth during three oceanographic expeditions, we describe in detail the morphology of the identified specimens, including the description of the pygidium, so far unknown in this species, and provide SEM photographs to support their identification. Paraprionospio treadwelli was originally found in Chesapeake Bay, Northwestern Atlantic, and we now extend its distribution southwards to the Western Gulf of Mexico. Remarks on the environmental conditions where this spionid species was found and the observed abundance seasonal pattern are also provided.

Background: Increasing influenza vaccination rates can significantly reduce the onset of severe symptoms and the risk of complications, thereby alleviating the burden on hospitals during flu seasons. However, the overall vaccine uptake has been decreasing in the United States, which is expected to increase the burden of disease. This study aims to estimate the impact of low influenza vaccination rates on disease burden and U.S. hospital system resources. Methods: The impact of reduced flu immunization rates was estimated using a dynamic age-stratified transmission model. Two U.S. flu seasons (2011-2012 for low incidence and 2017-2018 for high incidence) were analyzed to simulate flu epidemic variations. This study assessed four different flu vaccination rates: 25%, 30%, 35%, and 40%. Outcome measures included the number of infections, outpatient visits, hospitalizations, intensive care unit (ICU) stays, and deaths. The flu vaccine effectiveness (VE) rate was taken from CDC reports, estimating an average VE of 42% for all ages over the last 10 seasons. Vaccination rates by age group were also estimated using CDC reports, assuming immunization with quadrivalent flu vaccines for all ages. The total number of acute hospital and ICU beds available for influenza in the U.S. was assumed to be 300,000 and 30,000, respectively. Results: Using the U.S. flu immunization rate from the 2023-2024 season (approximately 35%), a high flu incidence season is expected to result in 71 million symptomatic infections, 29 million office visits, 0.94 million hospitalizations, and 133,670 deaths. Any scenario with an immunization rate below 45% will generate significant pressure on the U.S. hospital system and saturate the number of ICU beds during high incidence seasons. Only increasing the flu immunization rate to 50% or higher may prevent the saturation of acute hospital or ICU beds, regardless of the flu season’s incidence. Conclusions: The analysis shows the critical need to increase U.S. flu immunization rates to at least 50% to improve health outcomes and avoid the saturation of hospital system resources, especially ICU beds.

Background: In 2024, US hospitals were affected by the Becton Dickinson (BD) BACTEC blood culture bottle shortage with little time to respond and conserve supply. The extent of the impact of this shortage on clinical practice has not been explored. Methods: We developed a 7-question online poll with the Emerging Infections Network (EIN) exploring the extent to which facilities were impacted by the shortage, geographic distribution and facility type of institutions affected, actions taken to mitigate the shortage, and the impact on clinical management of fever and Staphylococcus aureus bacteremia. The link was sent to >3100 EIN listserv members 3 times during September 2024. Descriptive and thematic analyses were performed on quantitative and qualitative responses. Results: Of 202 respondents from 39 states, 129(64%) responded their hospital had limited blood cultures available, 8(4%) were unsure how their hospitals were affected, and 65(32%) indicated their hospitals were not affected (Fig1). The most affected hospital facility types with >10 respondents were Community (27/39, 69%), University (48/72, 67%), Children’s (7/11, 67%), Non-university teaching (33/52, 65%), and the VA/DOD was least affected facility type (3/11, 27%). Respondents not affected by the shortage most commonly used alternate blood culture media. Top mitigation strategies included publishing algorithms for best practice use (103/202, 51%), restricting follow-up blood cultures (88/202, 44%), using single blood culture sets (86/202, 43%), and implementing EMR-based alerts on blood culture orders (71/202, 36%). Important clinical themes identified by affected respondents included limitations on blood culture use (147 responses), concerns with overall treatment and care including delays and disruptions in discharges or prolonged antibiotic use (15 responses), concerns with bacteremia management (15 responses), and increased diagnostic stewardship opportunities (21 responses) (Fig2). The most prevalent theme in S. aureus bacteremia management was limitations in repeat blood cultures (61/163, 37%) with concerns about confirming bacteremia clearance, while the most common theme in inpatient/ER management of fever was limitations in initial blood cultures (64/159, 40%), with common comments about reducing inappropriate blood cultures. 61/202 respondents commented in the open-ended question with the most common theme highlighting increased diagnostic stewardship as a positive outcome of the shortage (19/61, 31%). Conclusion: The BD BACTEC blood culture bottle shortage caused widespread clinical impact. The themes identified highlight the challenges placed on healthcare systems during times of shortage as well as the effects on patient care. Mitigation strategies implemented during the shortage may create future opportunities for diagnostic stewardship.

Background: Hand hygiene is an important strategy for reducing healthcare-associated infections. While efforts to improve nursing home (NH) staff hand hygiene have been prioritized, there are few if any policies in-place to improve resident hand hygiene. Further, CMS guidance requires that residents be bathed “twice a week.” The objective of this study was to characterize resident hand hygiene knowledge and habits as well as bathing practices to identify barriers in a setting where new intervention strategies could be aimed. Methods: The survey was administered at 20 NHs across the United States between December 2023 and July 2024. Verbal consent was obtained from residents before survey administration. Survey questions explored residents’ hand hygiene knowledge and differences in hand hygiene habits and bathing practices since entering the NH from their last place of residence. Three knowledge-based questions assessed residents’ understanding of the recommended length of time to wash hands and use hand sanitizer in addition to when hand washing should be utilized instead of hand sanitizer. Frequency of hand washing, either through soap and water or hand sanitizer, instances of when and how residents wash and dry their hands, and whether resident’s faced challenges were assessed. Results:Of the 495 residents who completed the survey, only 142 (29%) residents answered all three knowledge-based questions correctly. Residents who answered two or three questions correctly reported washing their hands more frequently at their previous residence compared to residents who answered zero or one correct (Figure 1). Frequency of hand hygiene was lower at the NH compared to their previous residence across a variety of indications (Figure 2). More residents faced challenges with washing their hands at the NH compared to their previous residence (30% vs. 7%, P<.001). The most common challenges included: mobility limitations, medical issues, need for assistance, bathroom accessibility and inadequate bathroom supplies/equipment. About half the residents (53%) reported never being reminded to wash their hands; 60% reported that they would use hand sanitizer if it was easily accessible. 51% of residents reported bathing with soap and water less at the NH compared to their previous residence with reported causes being needing help and not receiving it, nursing home policy, medical issues, and mobility limitations. Conclusions: Survey results indicate opportunities for interventions aimed at reducing the barriers to hand hygiene practice and improving bathing practices in NHs. Policy changes and hand hygiene educational opportunities addressing these barriers could serve as potential strategies.

Introduction: Grouping of medical tests in an order panel or set may facilitate standardized care but could have the unintended consequence of increasing unnecessary testing. At our institution, one such panel includes studies performed on stool for the purposes of diagnosing infectious diarrhea (Figure 1). We removed stool enterovirus polymerase chain reaction (PCR) from this order panel given limited data supporting its use in the diagnosis of the etiology of diarrhea. Objectives: We aimed to evaluate the impact of removing the stool enterovirus PCR from this panel and whether there were associated decreased costs from this intervention. Methods: We conducted an interrupted time series to estimate the initial impact of implementing this order panel, followed by the later removal of the enterovirus order from the panel, using gastrointestinal (GI) bacterial PCR orders as a control. Additionally, we conducted a cost-savings analysis by multiplying the cost per test by the decrease in tests/month after removing the order from this panel averaged over a year. Results: After the panel’s creation, there was an immediate significant increase in enterovirus stool PCR ordering from a predicted mean of 28 tests/month to 43 tests/month (difference of 15 tests/month, p < 0 .0001) (Figure 2, blue). Similarly, the bacterial stool PCR ordering increased from a predicted mean of 98 tests/month to 136 tests/month (increased by 37 in the month following panel creation, p < 0 .0001). Conversely, after the removal of enterovirus PCR from the panel, there was an immediate significant decrease in testing from a predicted mean of 60 tests/month to 17 tests/month (decreased by 43 tests/month, p < 0 .0001), without a significant change in bacterial stool PCR ordering (16 test/month decrease, p=0.10) (Figure 2, red). We estimate that this simple intervention will save an average of $8,500 annually in direct costs each year. Discussion: Enterovirus PCR ordering significantly increased after the introduction of an order panel bundling stool studies targeted at diagnosing diarrhea. When this order was removed from the panel, there was a significant decrease in ordering without a change in infectious stool testing overall, as evidenced by no significant change in GI bacterial panel ordering. We hypothesize that clinicians utilize this panel to craft a differential for acute-onset diarrhea. Therefore, when the stool enterovirus PCR option was removed from this panel, it is possible that it was no longer considered on the differential. Reviewing such order panels may be helpful in reducing unnecessary testing and costs to healthcare systems.

Introduction: First responders, including EMS and fire personnel, are essential to public safety, often facing high-risk environments with infectious agents. However, IPC training varies across the U.S., creating preparedness gaps. This study identifies training needs through a nationwide survey to offer evidence-based recommendations for effective IPC training, improving safety for first responders and the communities they serve. Methods: This study used an online survey to gather feedback from first responders (n=183) across all 50 states. We used the convenience sampling method to select participants based on contact information obtained from the department’s website (n=1,208). We collected demographic data and asked participants to choose from 18 IPC topics they believed should be included in the training, with an option to suggest additional topics. Respondents also rated the factors that influenced training effectiveness and indicated motivations for completing IPC training. An open-ended section allowed participants to share further opinions on IPC for EMS and fire services. Results: The most requested infection control topics were decontamination of apparatus and equipment (n=107, 7.21%), use of personal protective equipment (n=104, 7.01%), and transmission and types of communicable diseases (n=99, 6.67% each). The factors rated as most important in determining the effectiveness of training for EMS and fire personnel included “Examples of how the information applies to EMS and fire personnel” (n=76), “Inclusion of scenarios or real-world situations” (n=71), and “Availability of materials in a web-based format” (n=71). The main motivating factors for the completion of infection prevention and control training were identified as “personal health and safety” (n=99, 15.99%), “safety and health of my family” (n=93, 15.02%), and “safety and health of the patients” (n=90, 14.54%). Conclusion: These results signal that practical training with examples related to their field is preferred. A greater emphasis on real-life examples and web-based materials shows that the preference goes toward training that is relevant to daily operations and accessible in flexible formats. The first three motivational factors listed above emphasize the personal and professional stakes that first responders have in undergoing this training. This would therefore suggest that infection prevention programs need to be tailored to address the specific risks that first responders face and be delivered in ways that maximize engagement and practical application.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is a reportable hospital -acquired condition that can cause significant harm to hospitalized patients. Our facility, a 629 bed acute tertiary care hospital, continued to observe Healthcare Facility-Onset (HO) MRSA bacteremia rates above the corporate goal despite our housewide MRSA decolonization protocol consisting of daily chlorhexidine gluconate bathing (CHG) and an alcohol nasal antiseptic twice per day for all adult inpatients ≥ 18 years of age. This prompted us to conduct a gap analysis and evidence-based practice review to address our current MRSA decolonization practices. Methods: In January 2024, a revised MRSA decolonization protocol was implemented for our adult inpatient population consisting of the addition of nasal mupirocin twice per day for 5 days for all Intensive Care Unit (ICU) patients, MRSA nasal screening for high-risk patients, and implementation of contact precautions (gown, gloves) for patients identified or known with MRSA colonization and/or infection. The nasal alcohol antiseptic was removed from the revised protocol. Multidisciplinary education on the protocol changes (MRSA screening, isolation, and discontinuation of the nasal antiseptic) were disseminated to nursing, pharmacy, and the medical staff. Mupirocin was added to the standing ICU order set in the electronic medical record (EMR). Pre-intervention (February 2023 - January 2024) and Post-intervention (February 2024-October 2024) time periods were used to assess the impact on the rate of HO MRSA bacteremia and were obtained from The National Healthcare Safety Network (NHSN) standardized infection ratio (SIR) 2015 baseline with analysis using the NHSN statistics calculator. Results: Following implementation of the decolonization protocol, the MRSA bacteremia cumulative SIR decreased 91% from 1.077 to 0.096 which was statistically significant with a two-tailed p-value of 0.0021 (95% Confidence interval: -99.6, -49.5). The housewide MRSA bacteremia rate decreased from 1.05 infections per 10,000 patient days to 0.090 per 10,000 patient days which reflected a significant decrease (p: 0.0016). The ICU MRSA bacteremia rate also showed statistical significance with a decrease from 4.2 per 10,000 patient days to 0.00 per 10,000 patient days (p: 0.0477). Conclusion: Revising the MRSA decolonization protocol significantly decreased our MRSA bacteremia rates. This included re-implementation of contact precautions, screening high-risk patients that could be carriers of MRSA, and mupirocin decolonization for ICU patients. Facilities should consider evaluation of their MRSA decolonization, isolation, and screening practices if unable to decrease their HO MRSA bacteremia rates.

Background: The prevalence of multidrug-resistant organisms (MDROs) in the post-acute care setting is well-documented in adults. Few studies have investigated the prevalence in children. Methods: We performed a prospective, single-center study including children with tracheostomy tubes age 2 months to 17 years admitted to a 24-bed post-acute care unit within a quaternary care children’s hospital. Index respiratory and stool specimens were obtained within two weeks of admission. Subsequent specimens were obtained weekly thereafter for up to eight weeks. MDROs were identified using methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase Enterobacterales (ESBL-E), and carbapenem-resistant Enterobacterales (CRE) selective media (CHROMagar, Hardy Diagnostics). ESBL-E and CRE colonies were additionally plated onto MacConkey agar and only lactose fermenting organisms were considered positive. Index MDRO status was defined using week one samples; if not available, week two results were substituted. New MDRO acquisition was defined as a negative index MDRO culture with a subsequent positive culture. Results: A total of 47 children were enrolled. Median age was 9 months (interquartile range [IQR], 5-31 months) and median hospital length of stay prior to post-acute care admission was 89 days (IQR 27, 158). The most common pre-existing medical conditions were congenital heart disease (19, 40%), severe neurologic impairment (19, 40%), and prematurity Conclusion: MDROs are common in children hospitalized in the post-acute care unit. Nearly half of this cohort acquired CRE following admission, highlighting the need for strict infection prevention and control measures and tailored empiric antibiotic strategies.

In this paper, we study the distribution of the temperature within a body where the heat is transported only by radiation. Specifically, we consider the situation where both emission-absorption and scattering processes take place. We study the initial-boundary value problem given by the coupling of the radiative transfer equation with the energy balance equation on a convex domain $ \Omega \subset {\mathbb{R}}^3$ in the diffusion approximation regime, that is, when the mean free path of the photons tends to zero. Using the method of matched asymptotic expansions, we will derive the limit initial-boundary value problems for all different possible scaling limit regimes, and we will classify them as equilibrium or non-equilibrium diffusion approximation. Moreover, we will observe the formation of boundary and initial layers for which suitable equations are obtained. We will consider both stationary and time-dependent problems as well as different situations in which the light is assumed to propagate either instantaneously or with finite speed.

Between the mid-seventeenth and the late-eighteenth centuries thousands of enslaved people were brought to the British Isles. Many were enslaved, and they were publicly bought and sold, marked by brands, collars and manacles, and some were sent from Britain into plantation slavery. Slavery did not, hoverer, flourish in Britain. By the time of Somerset v Stewart (1772) and Knight v Wedderburn (1778) the large majority of people of color in Britain were free, many of them self-liberated. Despite the best efforts of enslavers to maintain their property rights in people, the enslaved regularly escaped. Newspaper “runaway advertisements” were invented in London during the second half of the seventeenth century, and between the 1650s and 1770s they reveal the development of the freedom seeker in the public sphere. The Somerset and Knight decisions did little to change slavery in the British Isles but rather confirmed a change that was all but complete. The most significant impact of the decisions was in the colonies, where planters interpreted the courts’ actions as evidence of a growing imperial threat to the institution of slavery

Background: The adult bone marrow transplant (BMT) unit at an urban academic medical center in the Midwest reported the highest number of central line-associated bloodstream infection cases across the health system in 2022 and 2023 and notably had the second-highest volume of blood culture specimens collected when compared with other patient care units. Statistical analysis comparing BMT patients to a sample group of oncology patients with the same length of stay and central line days demonstrated that BMT patients had a median of 17 blood cultures per admission compared to 7 in the sample group (p-value 0.000). Moreover, a review of 21 weeks of BMT patient blood culture specimen results suggested that patients were undergoing cultures who were unlikely to have bacteremia or sepsis. Method: An interdisciplinary team created a nurse-driven, clinical decision-making algorithm to refine the release of blood cultures from a conditional order set for BMT patients. The objective of the algorithm was to safely reduce the number of blood culture specimens. It includes an updated fever threshold to align with national neutropenic fever guidelines, consideration for new-onset clinical instability, source of specimen collection, and time from the most recent blood culture. Analysis was completed on 827 cultures over 102 patient admissions in the pre-intervention period and 527 cultures over 162 patient admissions in the post-period. Balancing measures based on escalation of care were assessed by chart review. Results: When comparing blood culture specimens among BMT patients, the median specimen count per admission in the pre-intervention period was 6.0 (IQR = 3.5, 10.0), compared to 2.5 (IQR = 0.0, 5.0) specimens in the post-intervention period (p-value = 0.000). 37.7% of patient admissions were not cultured in the post-intervention period whereby 100% of patient admissions were cultured in the pre-intervention period. Of the 48 rapid responses, 10 intensive care unit transfers, and 1 code blue events in the 23-week post-intervention period, none were attributed to delayed detection of bacteremia or sepsis. Conclusions: Messaging that ordering providers should order fewer cultures is overly simplistic with consideration for the BMT patient population, yet diagnostic stewardship is essential to optimizing patient experience and outcomes. Attention to new clinical instability among BMT patients is important in detecting bacteremia. Stable symptoms in continuously observed BMT inpatients are unlikely to represent bacteremia.

Background: Wastewater-based epidemiology has demonstrated effectiveness in monitoring trends of viral infections at the city, state, and national levels. It captures data independent of testing intensity, providing a comprehensive biological sample of pathogens excreted in all secretions, that is unaffected by individual testing behaviors. Traditional healthcare-associated infection surveillance relies on case-based approaches, which can be resource-intensive, prone to misclassification, and may miss patients who are colonized. We aimed to evaluate the feasibility of implementing wastewater-based epidemiology in an acute care hospital for monitoring pathogens relevant to infection prevention and control. Methods: In this pilot study, we deployed a Teledyne ISCO 5800™ wastewater autosampler to collect weekly composite 1000 mL samples (15 mL every 151 minutes) from the final Stanford Hospital outflow point before wastewater merged with the community system. Wastewater samples were processed within 48 hours of collection. The solid phase was separated via centrifugation, followed by nucleic acid extraction employing silica-based purification techniques optimized for efficient inhibitor removal. Droplet digital PCR was conducted targeting pathogens previously validated by the WastewaterSCAN program (https://www.wastewaterscan.org/en/pathogens). We compared hospital wastewater nucleic acid concentrations with the number of positive tests/cultures at Stanford Hospital during the same period and with Wastewaterscan community wastewater data. Results: We collected three weekly composite samples: Jun 20–26, Jul 10–17, and Jul 18–25. Challenges included the location of the final outflow, and the autosampler’s size (132 x 74 x 84 cm and 88.5 kg). The outflow point was situated in a high-traffic area for patients and staff, requiring barricades to ensure safety and prevent interference with sampling equipment. In terms of interpreting results, viral nucleic acid concentrations (e.g., influenza, SARS-CoV-2) appeared to parallel the number of clinical cases and were similar to community wastewater trends (Figure 1). Most antimicrobial resistance genes, including vanA (Figure 2) and carbapenemase genes (KPC, NDM, OXA-48, VIM) (Figure 3), showed limited alignment with clinical cases; however, mecA exhibited some alignment (Figure 2). Hospital wastewater had higher resistance gene concentrations than community wastewater from San Mateo County (Figure 4). Conclusion: Continuous collection of hospital wastewater proved challenging, mainly from logistical issues such as equipment size and access limitations. Clinical respiratory virus trends appeared to be reflected in wastewater data. However, trends for antimicrobial resistance genes may be influenced by additional factors, such as the number of colonized patients, bacterial load in the hospital sewage system, hospital antimicrobial use, and antibiotic residues in wastewater.

This article considers the reciprocal duties proposed by the US administration, 2 April 2025. These are large import tariffs that will significantly disrupt the world trading system. Rather than considering the economic impacts of these tariffs, as others have and are doing, this article documents the rationale used to justify these destructive tariffs and their calculation. Using descriptive examples, the proposed duties are shown to be unfounded as reciprocal and generally ill advised.

Background: Invasive candida infections (ICI)are rare but a serious complication following cardiac surgery, The incidence of ICI ranges between 1-2%. There are a few studies describing the risk factors associated with candidal infections in this population. This study aims to evaluate the risk factors of ICI post-cardiac surgery. We hypothesize that judicious antimicrobial use and comprehensive wound care play a key role in prevention of ICI. Methods: We conducted a retrospective case control study of adult patients undergoing cardiac surgeries at an academic medical center from January 2023 to June 2024. Patients who underwent heart transplantation were excluded. For each case, four controls who underwent similar surgical procedures, two before and two after the cases, were selected. ICI was defined as the detection of candida species by culture or histological examination from a normally sterile site like candidemia or mediastinitis. Cardiac surgery included valve replacement, coronary artery bypass graft and durable cardiac device insertion. Data were analyzed for demographics, type of surgery, temporary mechanical circulatory support (MCS) use and timing, chest tube duration, tracheostomy, dialysis and Candida sp, colonization, defined as the isolation of candida sp. in the urine or airways without evidence of infection. Categorical and continuous variables were presented as frequencies and medians respectively. The variables were compared using Chi-square and Mann-U-Whitney. Results: There were 36 controls, and 9 cases included in the study. Patients who were younger (54 vs 66.5 years) and who had temporary MCS (66.7% vs 8.0%) were more likely to be diagnosed with ICI. Moreover, we found that delayed chest closure, more days with chest tube in place, dialysis, tracheostomy and candida colonization after surgery were also associated with increased risk of ICI (table). However, antimicrobial use prior to surgery was not statistically significant (72.2% vs. 88.9%) In terms of clinical outcomes, there was no statistical difference in mortality between the two groups (66.7% vs 91.7%), however patients were more likely to have longer length of hospital stay (42 vs 11 days, p=0.03). Conclusion: This study identified several risk factors for ICI post-cardiac surgery including temporary MCS use, delayed chest closure, prolonged chest tube placement and tracheostomy. While antibiotic use prior to surgery was not statistically significant, candida colonization post-surgery was identified as a risk factor. These findings highlight the importance of infection prevention strategies in the environment of care, such standardizing temporary MCS device care and optimizing wound care management, as