Background: Most laboratories diagnose Clostridioides difficile infection (CDI), using a nucleic acid amplification test (NAAT) or an enzyme immunoassay (EIA) for detecting the toxins in the stool. Adoption of a two-step testing method where a positive NAAT is folowed by a negative toxin EIA may lead to underreporting of patients with CDI healthcare-associated infections (HAIs). The possibility that patients with an active infection may be underreported has been suggested by data, that NAAT positive/Toxin negative patients are sometimes treated. Therefore a new surveillance definition has been adopted by NHSN, healthcare facility-onset antibiotic-treated C. difficile infection (HT-CDI). To date, the impact of adopting this new metric on the number of CDI cases that would qualify for HAI surveillance reporting remains unknown. We chose to explore this by retrospectively evaluating CDI cases using the current and proposed HT-CDI surveillance definition over a two year period in a sample of VA Medical Centers. Method: The above HT-CDI definition was applied to all acute care inpatients tested for CDI from July 1, 2022 through June 20, 2024 in 25 volunteer acute care VA medical centers. Centers were chosen based on the use of NAAT alone, NAAT followed by toxin EIA, GDH followed by toxin EIA with discordant results arbitrated by NAAT, GDH plus toxin EIA, toxin EIA alone, or GDH plus NAAT. A HT-CDI was defined according to NHSN as any qualifying C. difficile-positive asssay collected in an inpatient location on day 4 or greater after admission, along with administration of new qualifying antimicrobial therapy in a time frame window. Qualifying therapeutic agents for CDI were defined as enteral vancomycin, metronidazole, or fidaxomycin or intravenous metronidazole. Results: Analysis of the 789 CDI cases in 25 VA facilities collected over two years showed that adoption of the HT-CDI definition could potentially increase the number of reportable cases by 23.3%. The impact was most pronounced for patients diagnosed with two-step testing where presumably the patient would not be reported to a national database on the last test done. Conclusion: Application of the HT-CDI definition to Veterans Affairs patients could lead to an estimated 23% increase in the number of cases identified and eligible for reporting to a national database such as NHSN. These cases may be a better indicator of the true burden of CDI in an acute healthcare system.

Background: Healthcare produces 10% of US carbon emissions. Diagnostic stewardship can improve patient care while reducing emissions from unnecessary testing. In the Bronx, community outbreaks of Legionella pneumophila result in frequent testing, yet, most testing for Legionella and Pneumococcus are negative. The institution is transitioning from separate tests for Streptococcus pneumoniae and L. pneumophila to a single combined test. We evaluated the environmental impact of this change. Methods: To approximate emissions from separate versus combined testing kits, each kit component was weighed and converted to CO2 emission equivalents using the US Environmental Protection Agency (EPA) greenhouse gas equivalencies calculators. Using data from the previous 12 months and projecting similar future testing patterns, we estimated an emissions reduction based on combined testing. By multiplying waste emissions before and after combined testing, we were able to estimate the emissions diverted by this institutional change. Results: From January 2023 to November 2024, 13906 urine Legionella tests were performed and 62 (0.45%) were positive, while 12796 urine Pneumococcal tests were performed and 479 (3.74%) were positive. Separate testing kits generated 218.2 kg of plastic waste and 749.1 kg of paper waste. Projected plastic waste from January 2025 to November of 2026 using the combined test is 48.5 kg of paper waste and 64.2 kg of plastic waste. The total estimated emissions reduction is 4.34 Kg of CO2. Conclusions: Diagnostic stewardship via a combined urinary antigen test can reduce waste from unnecessary testing without altering workflow. This institutional change is projected to reduce the plastic waste equivalent to 8480 water bottles and reduce emissions equivalent to using 11 gallons of gasoline or charging 340 smartphones. Our calculations are likely an underestimate of total emissions diverted since we only estimated emissions produced by waste in the landfill and did not account for other associated emissions such as those produced by transporting the waste. While the impact is modest, diagnostic stewardship applied broadly is a step towards a goal of net zero.

Introduction: Studies examining carbapenemase producing carbapenem resistant Enterobacterales (CP-CRE) transmission incorporating clinical and genomic data in Indian hospitals are lacking. We investigated the prevalence, risk factors for CP-CRE peri-rectal colonization on admission and acquisition during hospital stay and genomic epidemiology of CP-CRE isolates in an adult surgical intensive care unit (SICU) in a tertiary-care hospital in India. Methods: SICU patients admitted from July 31 to November 30, 2023 were prospectively enrolled. Peri-rectal swabs (PRS) were collected at SICU admission and discharge, and hospital discharge. Environmental sampling of sinks was performed. Swabs were plated on selective agar (CHROMagarTMmSuperCARBATM) for CP-CRE isolation. Whole genome sequencing of CP-CRE isolates was performed to investigate antimicrobial resistance gene (ARG) abundance, strain typing (ST), and relatedness classified by community-associated (CA), healthcare-associated (HCA), hospital-acquired (HA), and environmental isolates. Results: 56 (28%) of 203 enrolled patients were colonized with CP-CRE on SICU admission. Among 147 admission-negative patients, 113 had repeat PRS testing > = 1 times during their stay; 43 (29%; 43/147) acquired CP-CRE (Figure 1). The predominant organism in admission and acquisition cases was Escherichia coli (52%) and Klebsiella pneumoniae (37%), respectively (Figure 2). Previous hospitalization = 2 antibiotics (aOR 2.77; 95%CI 1.12-6.82) were associated with admission CP-CRE colonization (Figure 3). In Cox regression analysis hospital stay before SICU admission was associated with CP-CRE acquisition in the SICU, but no risk factor was associated with acquisition during the entire hospital stay (Figure 4). Abundance of ARGs was lower in CA CP-CRE isolates compared to HCA, HA and environmental isolates (Figure 5). blaNDM and blaOXA genes were present in 79% (99/126) and 29% (36/126) of isolates, respectively; blaNDM-5 was the most common carbapenemase [65 (52%) of 126 isolates] (Figure 6A). E. coli ST410, which was associated with HA and HCA classifications was the most frequent ST (n=17) and 70% (12/17) carried NDM (Figure 6B). Twenty-seven E. coli and 17 K. pneumoniae isolates were separated by 20 or fewer core genome single-nucleotide polymorphisms, indicating potential relatedness amongst CP-CRE (Figure 7). Conclusion: More than 25% of SICU patients were colonized with CP-CRE on admission and also acquired CP-CRE during hospital stay. Healthcare-related CP-CRE isolates carried more resistances genes with NDM being the most commonly detected resistance gene in this cohort. Small sample size limited our understanding of risk factors associated with CP-CRE acquisition in hospital.

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: The pharmaceutical industry is estimated to have a larger environmental footprint than the automotive industry. Discarded and unused doses of pharmaceuticals generate financial waste and pollution, and exacerbate antibiotic shortages. The antibiotic daptomycin is dispensed in standard-sized single-use vials and dosed based on patient weight. Residual daptomycin in the vial after dose preparation must be disposed of and cannot be used for another patient. We hypothesized that daptomycin dosing nomogram use would reduce daptomycin waste, environmental impact, and financial costs. Methods: We performed a retrospective chart review quantifying daptomycin waste, defined as disposed of unused daptomycin, at Harbor-UCLA Medical Center, a 400-bed Level 1 Trauma Center, from 1/1/2023 to 12/31/2023. We then adjusted dosing using a daptomycin dosing nomogram. We modeled the difference in daptomycin waste (mg of daptomycin disposed of unused), pharmaceutical waste (weight of excess daptomycin vials required due to wasted antibiotic), and cost between the two dosing strategies. Our model assumed a daptomycin vial weight of 16.8g and cost of $30 per 500mg daptomycin vial. We conservatively estimated pharmaceutical waste as waste only from daptomycin vials, ignoring all other supplies and materials necessary to prepare daptomycin. Results: During the 1 year time period at our Medical Center, 138,882mg daptomycin was wasted. This level of daptomycin waste equates 4671g excess pharmaceutical waste and $8332 spent on unused, discarded daptomycin. In our model, we found that nomogram implementation would have reduced mean monthly daptomycin waste from 11,002mg to 1387mg (p<0.001). This reduction would have decreased the proportion of daptomycin wasted from a mean of 19% to 3% of all consumed daptomycin (Figure 1). Nomogram use would also have saved $7333 and averted 4111g of pharmaceutical waste in 2023. Conclusion: A daptomycin dosing nomogram would have prevented 122,322mg of daptomycin from being wasted and saved over $7000 at a 400 bed Medical Center over one year. Given the 4111 g of pharmaceutical waste is a conservative estimate, and ignores waste from other supplies/materials as well as upstream waste and emissions from daptomycin manufacturing, the overall generated environmental impact prevented by nomogram use is likely significantly higher. Our findings demonstrate that intentionally designed dosing strategies aimed at reducing drug waste can save hospital costs and reduce the environmental footprint of clinical care. When implemented at large health systems these strategies are likely to result in substantial cost savings and reduction in the negative environmental impact associated with pharmaceuticals.

Background: The overuse of antimicrobials contributes to the development of antibiotic resistance, the development of Clostridioides difficile infections, and increased patient morbidity and mortality. The impact of U.S. News medical school ranking on provider antimicrobial prescription is largely unknown. Our study aimed to assess whether there was a relationship between graduating from higher-ranked medical schools and the rate of prescribing antibiotics among Medicare Part D providers in the US. Methods: The ecological study obtained data from the Medicare Part D Prescribers (FY2013-2021) and the Doctor and Clinicians National repositories. The study’s main outcome was antibiotic days supplied per 100 beneficiaries. Secondary outcomes included antibiotic claims per 100 beneficiaries, days per claim, and antibiotic cost per 100 beneficiaries. A regression model was fitted to assess the relationship between provider medical school ranking and study outcomes. The study controlled for several state, provider, and patient variables. Results: A total of 197,540 providers were included (Table 1). No association was found between the medical school ranking and the rate of antibiotics days supplied per 100 beneficiaries (Table 2, Figure). Instead, the type of provider is associated with the prescription rates. Hospitalists and Emergency Medicine providers had fewer days supplied per 100 beneficiaries than Family Medicine providers. In contrast, students, more experienced providers (>20 years since medical school graduation), and females had more days supplied per 100 beneficiaries. Higher-ranking medical schools [1, 35], EM providers and hospitalists (vs. FM), and academic locations had lower claim rates per 100 beneficiaries, while students and experienced providers had higher claims. Days per claim were higher among providers from higher-ranked medical schools, more experienced providers, students, and academic locations, whereas they were lower among males, EM Providers, and Hospitalists. Costs per 100 beneficiaries were higher among students, academic locations, IM providers, and males; however, it was lower among EM and hospitalists. Conclusion: Our study showed no impact of medical school ranking on the overall rate of outpatient antibiotic prescriptions among Medicare Part D providers. While the claim rate per 100 beneficiaries was lower among providers from higher-rank medical schools compared to other providers, claims were prescribed longer, leading to similar days supplied and costs compared with other providers. This highlights the need for robust outpatient stewardship interventions and incorporating an outcome-based approach to antibiotic stewardship curricula in medical and mid-level provider schools.

Background: There are ongoing significant increases in antimicrobial resistant infections in hospitalized patients in the United States, emphasizing the importance of antimicrobial stewardship initiatives like appropriate antimicrobial use and accurate laboratory detection of infections. The special population of obstetric patients has received relatively limited focus in prior reports about antimicrobial stewardship opportunities. Methods: A retrospective observational review was conducted through a single large healthcare system’s electronic medical record to evaluate antimicrobial use in peripartum patients, defined as 30 days pre- or post-delivery. Our hypothesis was that most antibiotic use could be attributed to American College of Gynecology (ACOG) recommended therapy for common situations such as group B Streptococcus (GBS) prophylaxis, surgical site infection (SSI) prophylaxis, or intra-amniotic infections (IAI). Data regarding antimicrobial allergies were also collected. Results: Between April 2018 and July 2024, 77,062 mother-baby dyads were identified. 40,576 (52.6%) had antimicrobial utilization peripartum. Redundant antimicrobial coverage was common; most commonly cefazolin and penicillin (n=1402) and cefazolin and ampicillin (n=675). A subanalysis of 8528 (11% total deliveries) patients receiving the most common antimicrobials demonstrated 199 separate regimens utilized, 92 (46.2%) of which had duplicative spectrum of activity. The top three regimens were cefazolin and penicillin (n=126), cefazolin and ampicillin (n=51), and cefazolin and cefoxitin (n=47). 33 (16.6%) were in line with ACOG guidelines for GBS or SSI prophylaxis or IAI. 12 of the 33 (36.4%) were ACOG endorsed regimens with duplicative spectrum of activity. Allergies were common in the subanalysis cohort; 3957 (46%) patients had penicillin allergies and 816 (9.5%) patients had cephalosporin allergies. Conclusions: An administrative review of peripartum antimicrobials indicates significant opportunities for antimicrobial stewardship, particularly around antimicrobial coverage for conditions for which there is overlapping spectrum of activity, such as GBS prophylaxis with SSI prophylaxis. There are also significant opportunities in delabeling penicillin and cephalosporin allergies as there is the lead time of the pregnancy, usually with multiple touchpoints with obstetric care providers, to explore the accuracy of the allergy label. Steps to improve antimicrobial utilization around guideline-concordant antimicrobials with overlapping spectrum of activity as well as delabeling antimicrobial allergies will lead to decreased variability in antimicrobial prescribing in this population.

Background: Empiric antibiotic therapy choices and de-escalation practices for the management of febrile neutropenia (FN) can vary. Facility-specific antimicrobial guidelines have an important role in influencing prescription practices for FN and is a foundation of antimicrobial stewardship activities. Methods: This pre-post quality improvement study at the University of Maryland Medical Center (UMMC) Greenebaum Comprehensive Cancer Center evaluated the impact of the implementation of updated institutional FN guidelines. The changes primarily included: 1) removal of meropenem as first-line agent for patients receiving levofloxacin prophylaxis without other risk factors (e.g. history of resistant organism) and 2) de-escalation protocol for low-risk patients (e.g. afebrile, hemodynamically stable). Education of oncology attendings, residents and pharmacists were carried out. We included patients receiving antipseudomonal antibiotics for FN or sepsis as indicated by prescriber (~70% concordance with antimicrobial stewardship review). Sepsis was included because of high rates of observed misclassification for patients with FN. Stem cell transplant patients were excluded. Pre-intervention (04/2021 – 12/2022) and post-intervention (01/2023 – 09/2024) groups were compared for total anti-pseudomonal antibiotic and meropenem-specific days of therapy (DOT) per 1000 days present (DP) and count of unique antibiotic order per 1000 DP. In addition, a sample of antibiotics reviewed by the UMMC antimicrobial stewardship team was assessed for guideline compliance. Means were calculated across quarters for each period and Willcoxon rank sum was used for comparisons (p Results: A total of 3,311 antibiotics were ordered for FN (79%) or sepsis (21%) during the study period. Longitudinal trends and antibiotic type distribution are illustrated in Figures 1 and 2, respectively. DOT per 1000 DP for all antipseudomonal antibiotics was 213 in the pre-intervention group compared to 191 in the post-intervention group (p=0.06). Meropenem DOT per 1000 DP decreased from 105 in the pre-intervention group to 87 in the post-intervention group (p=0.004). Unique antibiotic order per 1000 DP of all antipseudomonal antibiotics remained constant (62 vs. 56, p=0.1), while unique antibiotic order per 1000 DP for meropenem decreased (16 vs. 8, p =0.01). Of the 317 antibiotics reviewed, 130/169 (77%) were guideline compliant in the pre-intervention group and 113/148 (76%) in the post-intervention group. Conclusion: Changes in FN guidelines at the UMMC cancer center led to decreased meropenem use with a nonsignificant decline in all antipseudomonal antibiotics. Additional work is needed to identify barriers to guideline adherence.

Background: Clostridioides difficile infection (CDI) disproportionately impacts hematology-oncology patients. In June 2022, our hospital implemented screening of asymptomatic patients admitted to the hematology-oncology unit to reduce CDI rates by early identification and isolation of C. difficile carriers. We evaluated the impact of admission screening on rates of CDI and compared incidence of diarrhea and subsequent symptomatic testing stratified by asymptomatic admission testing result. Method: During the intervention period (July 2022 – July 2024), asymptomatic patients admitted to the hematology-oncology unit were tested for C. difficile (perirectal swab, Cepheid GeneXpert®, Sunnyvale, CA). Guidelines for C. difficile symptomatic testing (unformed stool, Cepheid GeneXpert®) and treatment did not change between the baseline (May 2020 – May 2022) and intervention periods. Monthly CDI rates were calculated using CDC definitions based on clinical symptoms and positive C. difficile testing (community onset [CO] if positive in the first three hospital days, hospital-onset [HO] if day 4 or later). We performed an interrupted time-series analysis adjusted for repeated measures to compare CO-CDI and HO-CDI rates per 10,000 patient-days between baseline and intervention periods. The risk of developing diarrhea through hospital day 14 or being tested for symptomatic CDI during the intervention’s first year (July 2022 – June 2023) was analyzed using a cohort of asymptomatic C. difficile carriers and non-carriers in a 1:2 ratio, matched on hospital length of stay and date of admission. Result: The incidence rate ratio was 0.45 (P=0.10) for HO-CDI (Figure 1) and 0.15 (P=0.049) for CO-CDI (Figure 2) after screening implementation. During the first year of the intervention, 25 individuals were identified as asymptomatic C. difficile carriers by positive admission screen and were matched to a cohort of 50 asymptomatic non-carriers. There were no significant differences in development of diarrhea during hospital days 1-3 or days 4-14 between carriers and non-carriers (Table). None of the carriers received symptomatic C. difficile testing during hospitalization, compared to 20% of matched non-carriers (P=0.03). Conclusion: There was no significant change in HO-CDI rates and a statistically significant reduction in CO-CDI rates after implementation of C. difficile admission screening. Patients identified as carriers at time of admission were less likely to be tested for CDI during hospitalization than non-carriers, despite similar rates of diarrhea. Admission screening for C. difficile may reduce CDI rates through a variety of mechanisms; changes in provider testing behavior for patients previously screened for C. difficile may play a role.

Background: Catheter-associated urinary tract infections (CAUTIs) are a challenge for hospitalized patients accounting for approximately 40% of all healthcare-associated infections. CAUTI surveillance remains underdeveloped in many Sub-Saharan countries, even though identifying infections is critical to prevention and management. Standardized CAUTI surveillance among 45 LMICs conducted in intensive care units (ICUs) has demonstrated high CAUTI incidence compared to high-income countries. However, few studies have examined CAUTI in non-ICU settings in LMIC, where catheter use is common. We aimed to identify challenges in CAUTI surveillance related to documentation and antibiotic use patterns among adult inpatients in non-ICU wards in a Kenyan public hospital. Methods: Using a cross-sectional design, we retrospectively abstracted data on non-ICU adult inpatients from clinical and laboratory records. We identified patients with suspected UTI through urine culture requests from 1/1/2023-12/31/2023, whom we linked to clinical records. We abstracted data on diagnosis on admission, socio-demographics, urinary catheter indication and duration, UTI symptoms, urine culture results, and antibiotic use. This descriptive analysis summarizes characteristics of patients with suspected UTI to identify factors hindering CAUTI surveillance in non-ICU settings. Results: 293 non-ICU adult inpatients admitted to Mombasa Regional Referral Hospital had at least one urine culture request in 2023. Of these 193 (65.9%) had indwelling urinary catheters (IUC) inserted. Among those with IUC, 49.7% were female, with an average age of 51.5 years, with majority (64.8%) admitted to the medical wards; 5.2% had no recorded indication for catheterization and 82.9% had no UTI symptoms documented in the 2 days before the urine culture request. There were 124 negative cultures, 4 were determined to be contaminated, 6 did not have results on file, and 59 were positive; pathogens identified in the positive cultures included Escherichia Coli (51.8%), Klebsiella Pneumoniae (28.6%), Pseudomonas aeruginosa (10.7%), and others (8.9%) including Klebsiella Oxytoca, Acinetobacter baumanii, and Protein Mirabilis. 38.3% were prescribed intravenous antibiotics in the 7 days before the urine culture was obtained. 66.3% had no documentation of IUC removal, and 10.9% had incomplete documentation on file with missing pages. Conclusion: Myriad challenges to accurate CAUTI surveillance were identified among non-ICU patients at a Kenyan regional referral hospital. Lack of documentation of clinical symptoms makes application of standard case definitions challenging, and non-documentation of catheter removal dates hinders calculation of incidence using a catheter-day denominator. Further, the administration of antibiotics prior to urine culture hinders identification of potential source pathogens. Documentation and antibiotic administration practices are major hurdles for CAUTI surveillance.

Background: The diagnostic approach for Clostridioides difficile infection (CDI) significantly influences treatment and resource utilization. This study compares clinical characteristics and treatment choices based on three testing algorithms combining antigen and toxin enzyme immunoassay (EIA) tests and nucleic acid amplification tests (NAAT). Methods: We performed a retrospective study of patients tested for CDI between August 2022 and November 2024 in a large health system where multiple CDI testing algorithms are utilized: (arm 1) antigen and toxin EIA with automatic reflex to NAAT if discrepant results; (arm 2) NAAT with automatic reflex to toxin EIA if NAAT positive; and (arm 3) antigen and toxin EIA with NAAT at provider request with approval by Antimicrobial Stewardship. The last step in the testing algorithms determined whether the result was considered positive. We determined positivity rate by algorithm results and compared clinical variables including fever (temperature > 38.0° C) or abnormal white blood cell (WBC) count (12,000) within 48 hours prior to test order, laxative use within 24 hours prior to test order and treatment rates between those who tested toxin positive by EIA and those who tested toxin positive by NAAT only. Treatment was defined as receiving oral vancomycin or fidaxomicin for more than 5 days OR receiving those medications on the day prior to or day of discharge. Results: A total of 16,555 patients were tested. Overall algorithm positivity rate was highest in the EIA with reflex to NAAT (arm 1) at 13.7% compared to 5.7% for arm 2 (NAAT with reflex to toxin EIA) and 5.1% for arm 3 (EIA with NAAT at Provider Request). Toxin EIA positive patients were 1.2 times more likely than NAAT positive patients to display fever or abnormal WBC in the 48 hours prior to test order (p < 0 .001). Toxin EIA positive patients were less likely to receive laxatives compared to NAAT only positive patients. (p=0.11). Among toxin EIA positive cases, 89% received treatment compared to 57% in toxin NAAT only positive cases (p < 0 .001). 46% of patients who tested NAAT positive with a subsequently negative toxin EIA were treated. Conclusion: Patients with toxin EIA positive tests were more likely to exhibit systemic signs of infection and were treated at higher rates compared to NAAT-positive cases. While NAAT-based testing identified additional cases, many may reflect colonization. Treatment of toxin NAAT positive/toxin EIA negative patients was common highlighting opportunities for diagnostic stewardship.

Background: Carbapenem-resistant (CR) organisms (CROs) pose a serious public health threat. We examined the burden of CRO colonization, the proportion of CROs among clinical isolates, and infection prevention and control (IPC) practices in three hospitals in India. Methods: This study was conducted December 2023 to December 2024 in medical intensive care units (ICUs) at three hospitals in western India. CRO colonization was assessed by direct MacConkey method in rectal/stool specimens collected ≤24 hours after admission and weekly until colonization detection or ICU discharge, colonies < 25mm from carbapenem disks were processed for bacterial identification and carbapenem susceptibility. Proportion of CROs in clinical isolates was assessed by screening Gram-negative bacilli (GNB) identified for carbapenem susceptibility. CRO was defined as GNB resistant to any carbapenem. Carbapenemase production among Enterobacterales was detected by modified carbapenem inactivation method (mCIM). Fifty day shift hand hygiene (HH) observations were collected weekly to measure adherence. Fluorescent gel markers (FGM) were placed on high-touch surfaces (HTS) to assess environmental cleaning (EC); effectiveness was assessed by proportion of FGM removed the following day. Nine key EC indicators were observed weekly to monitor cleaning technique. HH and EC data included were from June 2024 to November 2024.

The epidemiological triad model (Population-Environment-Agent) is used to describe results. Results: Population: Over half (476 [55%]) of 869 patients screened at ICU admission were colonized with CROs. An equal proportion of colonization was observed among patients without prior healthcare exposure in last 90 days (55% [217/396]). Of the 660 GNBs isolated from clinical specimens, 60% were CROs. Environment: CRO colonization was acquired by 65% (20/31) of the patients who remained in ICU for ≥ 7 days. Average HH adherence was 50% (30%-69%). HTS cleaning effectiveness averaged 65% (50%-77%). Adherence with correct EC technique was 77% (53%-86%). Agent: Among clinical isolates, 92% Acinetobacter-baumannii-complex, 70% Klebsiella pneumoniae, and 47% Escherichia coli were CRO. K. pneumoniae (35%) was the most frequently isolated CRO followed by A.baumannii-complex (33%) and E.coli (16%). Among colonization screening swabs, E.coli (57%) was the most frequently isolated CRO followed by K. pneumoniae (23%) and A.baumannii-complex (10%). 96% of CR Enterobacterales among clinical isolates and colonization screening were carbapenemase producers. Conclusions: The high prevalence of CRO colonization, acquisition rate, and carbapenem resistance indicate a high level of CRO threat in these Indian ICU settings with suboptimal IPC measures. There is an urgent need to strengthen IPC practices to interrupt transmission in healthcare settings.

Background: Skilled nursing facilities (SNFs) face many challenges implementing robust infection prevention and control (IPC) programs. The Philadelphia Department of Public Health (PDPH) partnered with APIC Consulting Services, a wholly owned subsidiary of The Association for Professionals in Infection Control and Epidemiology (APIC), to provide IPC mentoring to Philadelphia SNFs. The objective of the program was to strengthen IPC capacities by providing an in-depth IPC assessment followed by an action plan and longitudinal infection preventionist (IP) support to mitigate identified gaps. Methods: A health equity framework based on area deprivation index (ADI), percent of residents on Medicaid, and Centers for Medicare & Medicaid (CMS) star rating was developed to identify priority SNFs for recruitment into the voluntary program. Participating SNFs received a three-day onsite IPC assessment with an expert IP consultant using an expanded version of the Centers for Disease Control Infection Control Assessment and Response (ICAR) tool. Assigned consultants provided mentorship and education for the SNF IP for up to six months. Each facility identified 4-5 focus areas and co-developed an action plan with the consultant. SNF assessment data collected July 2023 -May 2024 were analyzed to assess IPC gaps across facilities. Results: Participants included 11/46 (24%) Philadelphia SNFs, including 8/18 (44%) priority facilities. Median facility size was 189 beds and median census was 164 residents. Program completion rate was 73%. Consultants performed 66 onsite visits and 26 remote visits, totaling over 1,752 hours of support. Median number of IPC gaps identified was 79 (IQR: 57-84), most frequently within the domains of environmental cleaning and disinfection (13%); water management (10%); and training, auditing, and feedback (9%). Common facility-chosen action plan focus areas included disease surveillance (24%), antibiotic stewardship (16%), and hand hygiene (13%). Main barriers to program completion included lack of leadership support (18%) and staff turnover (9%). Conclusions: Expert-driven longitudinal support can be an effective strategy for enhancing IPC capacity within low resourced SNFs and a data-based health equity framework can be used to prioritize facilities for support. Through targeted mentorship, this program identified and addressed gaps in IPC practices and fostered a culture of safety. Most common action plan focus areas selected by the facilities did not align with IPC topic areas where most recommendations were given, highlighting potential SNF IPC program areas that may be challenging for facilities to address and where further education and resources are needed.

Background: Following the identification of Legionella pneumophilia by next generation sequencing (NGS) testing in an immunocompromised patient in June 2024, an extensive environmental sampling initiative was launched to determine possible contamination sources. Method: The water management team was immediately notified and performed initial testing on the unit where the positive case was identified, in which six ice and water machines, two showers, and four sinks were all sampled from two inpatient oncology units. Result: Only 4 of the 270 identified ice machines were tested every quarter. Since there was no randomization in the testing, this did not provide an accurate representation of the effectiveness of the hospital’s water management system. The results identified an ice machine located in a low traffic area of the unit which resulted positive for Legionella pneumophilia. Conclusion: Our findings led to the identification of the implicated ice machine in a low traffic area of the unit as our primary source, highlighting the need for more robust water monitoring practices across high-risk areas. When interviewing the nursing team, it was mentioned that the patient frequently requested ice chips to consume due to oral lesions, and nursing flow confirmed the impacted ice machine was the source of the patient’s ice chips. In response, we expanded water testing protocols from 4 (1%) to 22 (8%) randomized ice machines in quarter three testing, resulting in the identification of 10 of the 22 machines testing positive for Legionella, a 45.5% positivity rate. This allowed us to change our water testing program moving forward to include 120% more ice machines in the quarterly testing program. We also implemented a phased approach to address the low flow machines throughout the hospital that are at risk of bacterial production in which we are gradually installing flow meters and monitoring usage for approximately one to two months per machine. Machines that are deemed low flow will be removed from the unit. We aim to reduce low flow ice machines on the inpatient units by 50% by the end of quarter 4 in 2025. These changes have reinforced our commitment to patient safety by limiting pathogen exposure and operating from an infection prevention standpoint. This investigation underscores the critical role of environmental monitoring and ongoing assessment of water-related equipment in healthcare settings.

Background: Measles cases have been increasing in the United States and globally. However, the nonspecific presentation and ability to mimic and coexist with other common infections can delay diagnosis. During July 2024, a 12-year-old patient fully vaccinated for measles with recent international travel was admitted to an acute care pediatric hospital with fever, rash, mouth sores, and cough and initially thought to have a common viral infection. Rash progression during hospitalization prompted measles polymerase chain reaction (PCR) testing, which was positive. The hospital rapidly conducted contact tracing and infection prevention (IP) efforts, including quarantine, symptom monitoring, and postexposure prophylaxis (PEP) administration, to prevent secondary measles transmission. Methods: The patient was placed on airborne isolation ~24 hours after presentation, pending measles testing results. After notification of the positive PCR test, hospital IP staff performed unit walkthroughs and reviewed security footage to retrace the patient’s movements. Staff determined the patient was transported for an echocardiogram, chest radiograph, and walked about the emergency department before isolation. Findings were used to identify contacts requiring quarantine, immunity testing, and PEP. Contacts were notified and those within the PEP window period who were immunocompromised or without presumptive evidence of immunity were offered PEP. All contacts were monitored for development of measles infection. Results: Within 36 hours, 158 staff contacts and 90 contacts among patients and visitors were identified, including 9 infants and 24 patients with incomplete measles immunization. At completion, the investigation identified 350 contacts, including 187 staff, 73 patients, and 90 visitors. The hospital administered PEP to 24 staff, 21 patients, and 6 visitors in accordance with American Academy of Pediatrics Redbook recommendations. Among 51 PEP recipients, 2 patients received intramuscular immunoglobulin, 8 patients received intravenous immunoglobulin, and 41 contacts, including all staff and visitors receiving PEP, received MMR vaccine. Six staff members who had no evidence of immunity were furloughed from work for 21 days after index patient contact. No secondary infections were reported. Conclusions: A single measles case resulted in 350 contacts among patients, visitors, and hospital staff, exemplifying the broad reach measles can have in healthcare settings. This event highlights the need for a high level of suspicion to promptly identify, isolate, and test possible measles patients. Secondary transmission can be prevented through thorough and coordinated investigations to identify all contacts at the facility, rapidly placing contacts without immunity in quarantine, and mobilizing resources to ensure timely PEP administration to eligible contacts.

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

Background: Patients with multidrug-resistant organisms (MDROs) often require prolonged contact isolation, negatively impacting patient care and resource utilization. De-isolation criteria for MDROs vary across pediatric hospitals, typically based on organism type and achieving negative cultures. This study assessed the impact of revised MDRO de-isolation criteria allowing shorter contact isolation (Table 1) on healthcare-associated (HA) MDRO incidence rates in a freestanding academic pediatric medical center. Methods: We measured HA-MDRO incidence (MDROs listed in table 1, identified on or after hospital day 3) per 1000 patient days during two periods: (1) Pre-intervention (January 2019 – February 2022), prior to revised de-isolation criteria, and (2) Post-intervention (March 2022 – July 2024). Negative binomial regression was used to compare the level and trend of HA-MDRO incidence rates between the periods. Results: The incidence rates of all HA-MDROs, extended-spectrum beta-lactamase (ESBL)-producing organisms and methicillin-resistant Staphylococcus aureus (MRSA) are shown in Figure 1. No significant difference was observed in the level (p=0.38, 0.37, 0.9) or trend (p=0.67, 0.82, 0.76) of HA-MDRO, ESBL, or MRSA incidence rates between the periods. Estimating a daily cost of about $43 for personal protective equipment only, a minimum reduction of two weeks of contact isolation translates to approximately $602 cost reduction per patient. Conclusion: Shortening the duration of contact isolation for MDROs did not increase HA-MDRO incidence rates in our children’s hospital and may offer cost savings. Carefully designed MDRO policies can enhance patient care without compromising infection prevention goals.

Background: Antimicrobial-resistant pathogens cause more than 2.8 million infections and 35,000 deaths annually in the U.S. Risks for antimicrobial-resistant infections are likely tied to social determinants of health. We assessed the relationship between ADI and targeted MDROs reported (mandatory and voluntary) to the Philadelphia Department of Public Health (PDPH), specifically: carbapenem-resistant Enterobacterales, Acinetobacter baumannii, Pseudomonas aeruginosa and Candida auris. Method: Confirmed MDRO case data were obtained from PDPH’s Communicable Disease Management System, PhilaVax, and CDC’s National Healthcare Safety Network for 04/2018 through 12/2023. MDRO patient home addresses were geocoded to census block groups, spatially mapped to zip codes using ArcGIS, and matched to ADI national percentile rankings and state decile rankings obtained from University of Wisconsin School of Medicine and Public Health’s Neighborhood Atlas website. Descriptive analysis using American Community Survey Data, calculation of MDRO prevalence rates by zip code, and Pearson correlation coefficients and simple linear regression between the MDRO cases and ADI were conducted using SAS 9.4. Missing and unknown values were excluded from descriptive analysis. Result: We analyzed 2436 MDRO cases reported to PDPH. Cases with race data (n=2138) were 51.9% Black and 34.1% White, compared to 43.3% Black and 38.0% White Philadelphia County population in 2023. Hispanic ethnicity was reported for 8.6% of cases (n=2101), while Hispanics represented 15.8% of the county population in 2023. Most patients with MDROs were ≥60 yo (60.1%). That age group was 55.5% male compared to the 42.5% male ≥60 yo county population. Most MDRO cases, 1846/2436 (75.8%), matched to Philadelphia zip codes and 1515/2436 (62.2%) matched to a census block ADI ranking. Three zip codes had a prevalence rate of >20 (M = 12, SD = 8; range 2-53) per 10,000 persons. Home address history for 356/2436 (14.6%) cases matched one or more congregate facilities, the majority of which matched a long-term care facility (286/2436, 11.7%). ADI percentiles and deciles positively correlated with the number of MDRO cases, r(86) = .62, p <.0001 and r(8) = .82, p = .0036, respectively. There was a significant effect of ADI percentiles and deciles on number of MDRO cases, F1,86 = 53.4, p Conclusion: There is a significant positive relationship between ADI ranking and MDROs in Philadelphia. The findings suggest a critical need for equitable outreach and interventions to address MDROs in both congregate facilities and communities experiencing greater deprivation.

Background: Antimicrobials are among the most prescribed medications in the hospital setting and intravenous antimicrobial use is associated with increased carbon emissions due to use of single-use disposable products for packaging, preparation, and administration. IV to PO antibiotic switch has been associated with lower waste and emissions and lower healthcare costs. This project aims to assess the effectiveness of pharmacist interventions in switching from intravenous to oral antibiotics and estimate emissions reductions. Methods: Our study population included adult patients hospitalized between October 1, 2023 and September 30, 2024 in one of twelve medical centers operating within a large, integrated healthcare system in Northeast Ohio. The primary intervention phase involved reinforcement of a pre-existing policy within our hospital system allowing pharmacists to convert certain highly bioavailable agents from IV to PO based on clinical criteria. The second intervention phase occurred as part of the hospital response to the nationwide IV fluid shortage beginning at the end of September 2024. We determined the rate of interventions occurring within the pre-intervention period and applied this rate to the intervention cohorts to determine what the expected number of interventions would be during these periods if the interventions would have had no effect. From the total days of therapy for each agent for each period, we estimated the total carbon emissions for each period, using our antimicrobial carbon emissions calculator. Results: Compared to the pre-intervention group, the rate ratio for the second intervention phase was 2.97 (95% CI 2.61 to 3.37). The second intervention group rate versus the first intervention rate was 1.49 (95% CI 1.26 to 1.77). Using the difference between the actual and expected number of pharmacy interventions, the potential DOT saved using conservative (assuming 1 pharmacy intervention saves 1 DOT) and liberal (assuming 1 pharmacy intervention saves 3 DOT) estimates was determined, as well as the actual DOT saved based on the antimicrobial administration data. These values were used to calculate the carbon dioxide emissions and equivalents potentially and actually saved (Figure 2). The total actual emissions saved was less than both conservative and liberal estimates for post-intervention phase 1 versus pre-intervention phase, but it surpassed both estimates for post-intervention phase 2 versus pre-intervention phase. Conclusion: This is one of the first projects to estimate carbon emission reductions associated with IV to PO antibiotic switching. Future research should focus on identifying further opportunities to promote sustainable policies and measuring their impact.

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.