Background: Clostridioides difficile infection (CDI) remains a leading healthcare-associated infection (HAI) in the United States. To prevent outbreaks and transmission within healthcare facilities, providers must quickly recognize signs of CDI, correctly diagnose it, and implement measures to contain it. Nucleic acid amplification tests (NAATs) are highly sensitive but may over diagnose CDI, while toxin enzyme immunoassays (EIAs) risk false negatives. Two-step diagnostic algorithms have been recommended to improve diagnostic accuracy; however, national trends in their adoption have not been well described. Method: We conducted a secondary analysis of data from the Preventing Infections Through Appropriate Staffing (PITAS) study, which includes annual National Healthcare Safety Network (NHSN) hospital survey data from 347 U.S. acute-care hospitals from 2011-2024. Hospitals reported CDI testing methods annually, which were categorized as one-step, two-step, or other algorithms. Temporal trends in two-step testing adoption were assessed using mixed-effects linear regression with hospital as a random effect and adjustment for bed size and academic affiliation. Stratified analyses were performed by hospital size and academic status. Result: A total of 347 acute care hospitals contributed data from 2011-2024. In 2012, the predominant testing method was NAAT alone, which was utilized by 58% of hospitals while only 6.25% of hospitals utilized two-step methodologies. In 2017, the year of publication of the updated Infectious Disease Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) Clinical Practice Guidelines, 28.75% of hospitals used two-step methods. By 2024, 66.18% of surveyed hospitals utilized two-step methodologies for CDI. Academic hospitals consistently demonstrated higher adoption rates than non-academic hospitals (11.11% vs 2.92% in 2012 and 67.35% vs 59.18% in 2024). Hospitals with 501-1000 beds had significantly higher odds of adopting two-step testing compared with the smallest hospitals. Conclusion: Use of two-step CDI testing methods increased substantially in U.S. acute-care hospitals from 2011- 2024, particularly following the 2017 IDSA and SHEA guideline update. As hospitals increasingly adopt two-step testing, policymakers and healthcare epidemiologists should consider how testing methods influence reported infection rates.

Background: Since January 2025, critical structural and funding changes have altered the global healthcare landscape. To respond effectively, we performed a situation premortem. Premortem methods are commonly used within the field of implementation science to identify risk factors and early warning signs for failure of complex systems. Recognizing the systems-oriented nature of participant responses, we applied the socioecological model (SEM) to organize emergent themes. Methods In April 2025, a cross-sectional electronic premortem survey was distributed to IPC thought leaders. Participants were asked to imagine the year 2029 in which IPC research and practice had collapsed and to identify contributing factors, early warning signs, barriers, populations most affected, and missed opportunities for prevention or mitigation. Responses were analyzed using thematic content analysis. Themes were organized using the socioecological model to map findings across policy, community/professional, organizational, interpersonal, and individual levels. Results Nineteen of twenty-nine people agreed to participate (66.83% response rate) from the U.S., Australia, and Singapore. The majority (n = 13) were researchers with representation from clinical practice (n = 3), policy and regulation (n = 1), or in public health or professional capacity building (n = 2). Participants anticipated widespread consequences across all SEM levels (Figure 1). At the policy level, they described diminished IPC advocacy, global reversal of progress in infectious disease control, and increased economic burden. At the community and professional level, anticipated impacts included loss of public accountability, closure of training programs, reduced surveillance capacity, and fewer scholarly outputs to inform practice. Organizational consequences included inadequate funding of infection prevention/antimicrobial stewardship programs in healthcare facilities, workforce attrition, and increased legal risk. Interpersonally, participants anticipated inconsistent guidance and confusion, reduced support for frontline clinicians, decreased vaccine uptake, and diminished capacity to serve underserved populations. At the individual level, consequences included increased multidrug-resistant and healthcare-associated infections, fewer treatment options, lower vaccination rates, and increased morbidity and mortality among vulnerable, low-income, and immunocompromised individuals. Conclusion This premortem exercise highlights the potential impacts of a collapse of IPC research and practice. Participants anticipated cascading harms across multiple levels. These results identify areas for proactive, creative strategies tailored to specific socioecological domains of impact. Reliance on traditional federal funding models and the expectation for national data collection and reporting standards may be insufficient. The field must collaborate and develop alternative approaches to sustain IPC research, training, and practice to prevent negative downstream consequences and uphold professional values.

Authors and Affiliations: Frank Frankovsky III, Thane Thomas, Mark Sigler, MD, Joshua Preator, DO, James Morris, MD, MPH, FACEP, Jennifer Clary, MSN, RN, CIC, Stephanie Stroever, PhD, MPH Background: Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline 2.2.11 recommends replacement of central venous catheters inserted emergently under non-sterile conditions as soon as possible and ideally within 48 hours. The extent of compliance with this recommendation and associated outcomes in emergency department (ED)–placed central lines remains unstudied. Methods We conducted an observational study of adult patients admitted following central line placement in the ED at two hospitals in West Texas between June 2024 and August 2025. Patients who died in the ED were excluded. The primary outcome was time to central line removal or replacement after admission. Central lines were classified as emergent (non-sterile) if placed without maximal sterile barrier precautions and documented as such in a standardized ED log. Conditions of line placement were verified by investigator chart review and, when necessary, direct discussion with the team involved in placement. Patient demographics, indications for line placement, and clinical outcomes were abstracted from the medical record. Median time to removal or replacement was calculated for sterile and non-sterile lines and compared using the Wilcoxon rank-sum test; p-values <0.05 were considered statistically significant. Sensitivity analyses excluded patients who died after hospital admission. Results A total of 284 patients were included, of whom 121 (42.6%) had non-sterile central lines placed. Mean age was 64.5 years, with similar distribution by sex. Common indications for line placement included altered mental status (24.3%), cardiac arrest (19.0%), and shortness of breath (14.8%). Median time to removal/replacement was shorter for non-sterile lines than sterile lines (56.2 vs 90.7 hours; p = 0.038). This difference was not observed in sensitivity analyses excluding patients who died after admission (p = 0.775), suggesting survivorship or competing risk bias. No central line–associated bloodstream infections (CLABSI) were identified. Conclusion No CLABSI events were observed despite median central line dwell times exceeding the 48-hour threshold referenced in HICPAC guidance. Early mortality among patients with emergently placed lines may have limited the opportunity for infection to occur. These findings emphasize the role of concurrent infection prevention measures and highlight the need for multidisciplinary strategies to support timely replacement of emergently placed central lines.

Background: Multi-drug resistance is increasing, and insects may serve as critical reservoirs for these bacteria. While insects are part of the world’s natural flora and exist even in healthcare settings, their presence is often overlooked or disregarded. Current healthcare safety guidelines focus on keeping insects out but fail to address their potential contribution to nosocomial pathogen transmission, This study aims to determine the extent of knowledge regarding microbial transmission by insects in a healthcare setting. Methods: The systematic literature search utilized subject headings and preferred index terms such as “insects,” “microbial transmissions,” “insect vector,” “insecta,” and “cross infection” to construct a reproducible MEDLINE search within PubMed. This search was translated across Embase, CENTRAL, and select supplemental resources. Retrieved studies exceeded 1000 records, which were deduplicated using Covidence software, leaving 655 eligible articles for screening. A total of 36 peer-reviewed studies documenting insects in healthcare settings (e.g., hospitals, clinics, rehabilitation centers, ambulatory centers) were included and underwent data extraction and analysis. Excluded studies were non-English without translation or irrelevant to healthcare. Outcomes included identification of colonizing organisms, evidence of microbial transmission, and prevalence of multidrug-resistant pathogens carried by insects. Risk of bias was evaluated using the LEGEND criteria, and extracted data were synthesized following the Cochrane Review for Systematic Reviews in conjunction with the Joanna Briggs Institute (JBI) frameworks. Results: Of the analyzed studies the majority were from low- to middle-income countries and included the study of common insects such as cockroaches, ants, and various classes of flies. Studies included the examination of external surfaces and internal contents of the insects via evidence-based, aseptic collection and laboratory processes. Few studies demonstrated the likely transmission of bacteria via insect vector, though all studies demonstrated robust colonization of insect vectors with pathogenic microbes including multi-drug resistant bacteria. Conclusion: This review highlights the potential role of insects in microbial transmission in healthcare settings. However, most studies failed to establish a direct link between insects and pathogen transmission. Further research into areas such as multi-drug resistance transmission via insect vectors is needed.

In Antimicrobial Stewardship and Infection Prevention and Control, programmatic goals often strive to achieve clinical benefit by practice change in the direction of doing less. Practically, this may include reducing the number of tests ordered, encouraging shorter and more narrow courses of antimicrobials, or discontinuing practices that are no longer contextually appropriate. Because promoting practice change in the direction of doing less is a critical aspect of day-to-day operations in Antimicrobial Stewardship and Infection Prevention and Control, the goals of this Society for Healthcare Epidemiology Research Committee White Paper are to provide a roadmap and framework for leveraging principles of implementation and de-implementation science in day-to-day practice. Part II of this series focuses on some practical case studies, including real-world examples of applied de-implementation science to promote discontinuation of practices that are ineffective, overused, or no longer effective.

De-implementation of established practices is a common challenge in infection prevention and antimicrobial stewardship and a necessary part of the life cycle of healthcare quality improvement programs. Promoting de-implementation of ineffective antimicrobial use and increasingly of low-value diagnostic testing are cornerstones of stewardship practice. Principles of de-implementation science and the interplay of implementation and de-implementation are discussed in part I of this Society for Healthcare Epidemiology of America White Paper Series.In this second part of the series, we discuss a process for applying principles of de-implementation science in infection prevention and stewardship and then review some real-world examples and case studies, including a national blood culture shortage, contact precautions, and surgical and dental prophylaxis. We use these examples to demonstrate how barriers and facilitators can be mapped to evidence-informed implementation/de-implementation strategies to promote efforts to reduce low-value, ineffective, or out-of-date practices. These real-world examples highlight the need for infection prevention and stewardship programs to adapt to changing evidence, contexts, and conditions. Although barriers to practice change are often a bit different, de-implementation can sometimes be thought of as the implementation of a new program—but the new program aims to stop rather than start doing something.

As the saying goes, sometimes less really is more. Medicine and public health have a strong action bias and a strong aversion to risk and uncertainty. Although our best intentions may point us to implementing more interventions, often, the best medicine instead dictates that we do less, or nothing at all. Leveraging principles of de-implementation science can help move healthcare in the right direction when interventions are low-value, ineffective, or no longer needed.

Introduction: There are a number of tools available to healthcare epidemiologists for identification and investigation of healthcare-associated infections. For example, root cause analysis (RCA) is an evidence-based strategy for identifying process failures that resulted in infection. However, RCA is most valuable on a case-by-case basis. It is not an efficient tool for investigating numerous events that trend over time. Healthcare epidemiologists must use different strategies that are both efficient and powerful. A case-control study is a valuable option to investigate rare but recurrent infection events. The objective of this study was to demonstrate the utility of a case-control study design to detect attributable risk factors of cesarean section surgical site infections (SSI). Methods: We conducted a case-control study at a Level III childbirth center with data timeframe of January 1, 2021 to May 31, 2023. The project was approved by the institutions’ Quality Improvement Review Board prior to implementation. Cases were identified using the National Healthcare Safety Network (NHSN) SSI event criteria and included all levels of SSI. Controls were selected from the NHSN surgical denominator and were matched randomly without replacement by age at a 1:4 ratio. Variables were identified in collaboration with stakeholders based on known risk factors for SSI and abstracted manually. Analyses were conducted in Stata/MP version 17.0, and we performed multivariable conditional logistic regression with an alpha of 0.05 as threshold for statistical significance. The model was built according to a priori hypotheses and results from bivariate analysis of individual risk factors. Results: There were 32 SSI among 1709 cesarean deliveries, and all cases successfully matched with 4 controls for an analytic sample of 128. Bivariate analyses identified 7 relevant variables for inclusion in the multivariable model which narrowed down significant risk factors to 3: operative time (in minutes), post-operative chlorhexidine gluconate (CHG) bathing, and number of people in the operating room. Assessment of fit indices suggested an excellent fit with pseudo R-square of 0.526. Conclusions: This study demonstrated the utility of a case-control study design to identify attributable risk factors for relatively rare but significantly trending infection events. Not only is the design more efficient (e.g., time needed to abstract 50 data points for each patient), but it also employs statistical analyses that are often lacking in case-by-case investigations or RCA. It also has the power to narrow down risk factors for focused prevention efforts to get “the most bang for the buck.”

Background: Central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) cause significant morbidity and mortality among hospitalized patients. Over the last 10 to 20 years, hospital accountability for the prevention of device-associated infections increased at the state and national levels. For example, the Centers for Medicare & Medicaid Services implemented the Hospital Inpatient Quality Reporting Program in 2015. The objective of this study was to assess the impact of increased federal attention on infection prevention using longitudinal data from the National Healthcare Safety Network (NHSN). We hypothesize that there was a significant decrease in statewide standardized infection ratios (SIRs) for CLABSI and CAUTI over the last 8 years. Methods: We collected SIRs for CLABSI and CAUTI in acute care hospitals for all 50 states and Washington D.C. from the NHSN database from 2015 to 2022. For CLABSI, we performed unique analyses for critical care units, wards, and neonatal intensive care (NICU) locations. For CAUTI, we stratified by critical care units and wards. We included all states with more than 5 hospitals reporting data. Those with fewer than 5 were excluded by listwise deletion in the corresponding analysis. We tested trends over time using linear mixed effect models with year as fixed effect and state as random effect. We also included an indicator variable representing the influence of SARS-CoV-2 (Covid-19) on healthcare-associated infections (HAIs). We elected an alpha of 0.05 as the threshold for statistical significance. Results: Overall, CLABSI and CAUTI SIRs exhibited significant negative slopes (Figures 1-5) after controlling for the influence of Covid-19. Each analysis revealed progressively lower SIRs compared to the previous year except for the 2019-2020 interval. Interestingly, the linear trend resumed after 2020 with subsequently lower SIRs in 2021 and 2022. Covid-19 had a greater influence on CLABSI SIRs in critical care settings compared to ward or NICU locations. The slope of CAUTI SIRs were impacted less by Covid-19 in wards compared to critical care settings. Conclusion: The results of the analysis demonstrate that CLABSI and CAUTI are trending in the desired direction despite the HAI spike during Covid-19. Government and hospital stakeholders in the United States should be encouraged by the reported trends and continue to prioritize the funding and use of resources for evidence-based device-associated infection prevention.