Background: After CDC and local surveillance identified an increase in Klebsiella pneumoniae carbapenemase (KPC)-producing carbapenem-resistant Enterobacterales (KPC-CRE) caused by multiple organisms, an investigation was conducted at an acute care hospital. Cases clustered around an intensive care unit (ICU) and step-down unit (SDU), where wastewater plumbing was a suspected transmission source. Whole genome sequencing (WGS) was used to investigate this outbreak. Methods: A case was defined as detection of KPC-CRE or KPC (no organism cultured) from specimens collected at the hospital between 01/2019 to 10/2025. Clinical cases were identified via carbapenemase testing of CRE isolates using PCR (Xpert Carba-R) or by multiplex PCR panels and screening cases through PCR with reflex to culture. ICU sink and hopper samples and SDU sink samples were tested using selective media, MALDI-TOF, and multiplex PCR for KPC-CRE detection. Isolates underwent short and long-read sequencing. Result: Overall, 64 cases (37 clinical; 27 screening), involving 54 patients, were identified; 28 patients had ICU/SDU admissions during their hospitalization. The 52 cases with an organism identified included seven species, of which the most common were Citrobacter (26), Klebsiella (14), and Raoultella (5); 24 harbored blaKPC-2 (37.5%), 18 blaKPC-4 (28.1%), 5 blaKPC-3 (7.8%), 1 blaKPC-160 (1.5%), and 16 were not subtyped (25%). Seventeen isolates from five species carried blaKPC-2 on a 42 kb IncP6 plasmid, while ten isolates from five species carried blaKPC-4 on a 69 kb plasmid with Col440I and IncM1 replicons. Environmental sampling in 05/2025 found KPC-CRE in 10/12 sinks and 2/12 hoppers in the ICU and 1/22 SDU sinks (fig1). KPC-CRE environmental isolates were closely genetically related to the Citrobacter, Klebsiella, and Roultella clinical isolates and harbored similar KPC-carrying plasmids. Infection prevention and control (IPC) rounding identified patient items within the sink splash zone, including placing bath-in-a-bag in the sink. In 05/2025, a campaign was initiated to remove items from the splash zone, switch to chlorhexidine wipes, and implement daily use of an EPA-registered, sodium dichloroisocyanurate-based biofilm drain disinfectant product. Starting 07/2025, pouring of lipids and total parenteral nutrition down drains was stopped. While repeat environmental sampling in 6/2025 also found KPC-CRE in sink drains, no additional cases were identified in the ICU or SDU following these remediation activities (fig2). Conclusion: ICU sinks served as a reservoir for KPC-CRE, with transmission to patients. KPC-CRE persisted in drains following initial drain disinfection measures; therefore, changes in sink and splash-zone IPC practices appear to be important for interrupting transmission.

Background: Antimicrobial stewardship programs use the NHSN standardized antimicrobial administration ratio (SAAR) to monitor antimicrobial use (AU) and direct activities, but only certain locations generate SAAR values. We explored the correlation between hospital SAAR coverage using days present (DP) and facility-wide AU measured in days of therapy per 1,000 days present (DOT/1,000DP). Methods: We included Nebraska hospitals reporting at least one adult location and at least six months of AU data that generated a SAAR during 7/2024-6/2025. We classified hospitals by bed size [large: <150, medium: 26–150, and critical access hospitals: ≤25]. Days present from SAAR eligible locations were divided by total facility DP to calculate the SAAR coverage proportion. We categorized hospitals in the upper third as having high SAAR coverage and those in the lower two-thirds as low SAAR coverage. We calculated Spearman correlation coefficients to evaluate the strength of the association between SAAR and AU rates in the high and low SAAR coverage groups. Results: Overall, 45 hospitals were included (median 25 beds, range 7-641) with large variability among total days present (473-228,051). Regarding SAAR coverage, 14 hospitals were classified as low coverage and 31 had high coverage (representing 47% and 83% of total DP, respectively), with an overall median SAAR coverage of 91% (Figure 1). When comparing the all-antimicrobial SAAR with the total AU rate of the top 14 antimicrobials, hospitals with low SAAR coverage showed weak correlation (? 0.163, p-value=0.57) compared to those with high coverage (? 0.901, p-value=<0.001) (Figure 2). Performance varied for other NHSN SAAR categories and AU rates in the low coverage group, with higher correlation between the GRAMPOS SAAR category and vancomycin DOT/1,000DP, and lower correlation between the BSHO SAAR category and the total AU rate of cefepime/piperacillin-tazobactam/meropenem use (Figure 3). Conclusion: In hospitals with low SAAR coverage, SAAR values may not accurately reflect overall facility-wide AU. This discrepancy is especially evident when evaluating overall antimicrobial use. We hypothesize that the weak correlation is likely a result of substantial AU in locations that do not generate a SAAR. We noted variation in AU rates in hospitals with similar SAAR values which may stem from the CDC’s predictive model although incomplete capture of antimicrobial use may be playing some role as well. These findings support CDC efforts to expand the SAAR to include new locations.

Background: Nebraska (NE) Infection Control Assessment and Promotion Program (ICAP) is supported by the Nebraska DHHS Healthcare-Associated Infection (HAI) program via a CDC grant and works to assess and improve infection prevention and control (IPC) programs in all types of healthcare facilities. CDC recommends that outpatient healthcare facilities (OHFs) develop and maintain IPC programs; however, littleis known about the infrastructure of IPC programs in OHFs. NE-ICAP performed onsite assessments to review the implementation of best practice recommendations (BPRs) in these programs. Method: Onsite IPC assessments were conducted in OHFs from January 2020 to February 2024. The assessment questions were based primarily on the CDC 2016 Infection Control Assessment and Response (ICAR) tool, complemented by the CMS Hospital Infection Control Worksheet. Assessments included interviews and onsite observations. A total of 66 BPRs were assessed for implementation. Descriptive statistics were calculated using Microsoft Excel for assessment responses and demographic information. BPRs were classified based on hospital affiliation, accreditation status (based on certification by recognized accrediting bodies), and urban-rural designation (based on USDA rural-urban commuting area codes). The chi-square test for independence was performed in SPSS 20 to assess for statistically significant differences across these categories using a threshold of p < 0.05. Result: A total of 19 OHFs had onsite assessments. 42.1% had external accreditation, 77.8% had at least one individual trained in infection prevention regularly available, and 36.8% were considered urban (figure 1). Domains with the lowest compliance (percentage of BPRs in place) included injection safety (48.8%), device reprocessing (49.7%), and personal protective equipment (51.8%). Notable BPRs associated with less than 35% compliance are listed in figure 2. Accredited facilities demonstrated greater compliance with BPRs related to device reprocessing. Conclusion: Important IPC gaps exist in OHFs. Onsite assessments are crucial for evaluating IPC program infrastructure and highlighting areas for improvement. Further studies are needed to understand why accreditation is associated with better compliance with BPRs and the factors contributing to its success.

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

A Nebraska statewide webinar series was initiated during the coronavirus disease 2019 (COVID-19) pandemic for long-term care (LTC) and acute care/outpatient (AC) facilities. An impact survey was completed by 48 of 96 AC and 109 of 429 LTC facilities. The majority reported increased regulatory awareness (AC: 65%, LTC: 54%) and updated COVID-19 (AC: 61%, LTC: 69%) and general infection prevention (AC: 61%, LTC: 60%) policies.

Antibiotics are frequently prescribed inappropriately for acute respiratory infections in the outpatient setting. We report the implementation of a multifaceted outpatient antimicrobial stewardship initiative resulting in a 12.3% absolute reduction of antibiotic prescribing for acute bronchitis in primary care clinics receiving active interventions.