Background: Between October 2023 and July 2024, Methodist Hospital Specialty Transplant (MHST, San Antonio TX) experienced a cluster of five infections with Salmonella enterica serotype uganda among hospitalized kidney and liver transplant patients. All patients were symptomatic and specimens included blood, stool and urine. Salmonella enterica serotype uganda is rare with only a few reported outbreaks in the literature with none from healthcare settings. Methods: Investigation focused on two hypotheses: 1) a source within the facility was causing broad exposure but only severely immunocompromised patients were becoming symptomatic or 2) The clinical management of certain transplant patients is creating a risk of reactivation of Salmonella sp. The case definition was any solid organ transplant patient with a positive culture result (any specimen source) for Salmonella enterica serotype uganda post-transplant (no defined time) with or without symptoms who had a hospitalization at MHST after October 2023. The response focused on horizontal control measures (foundational infection prevention practices, water management), vertical control measures (food and nutrition services, patient screening) and epidemiologic descriptive analysis. Findings: Whole genome sequencing identified the five cases to be from an identical species. Cases occurred among kidney and liver transplant patients in roughly the proportion to the underlying census of these patients. No clinical or nutritional product or service was identified that would expose risk to transplant patients exclusively. There were no commonalities among the cases in relation to clinical care, procedures, or type of immunosuppression. Screening was performed for twenty-eight patients (either pre-liver transplant, post liver transplant or post kidney transplant) hospitalized between September and October 2024 with either chronic diarrhea or acute loose stools, none of which were positive for any species of Salmonella. Inspections of the kitchen showed opportunities around staff attire, food handling, food storage and the physical environment. Compliance to infection prevention assessments was 71% initially but improved to above 90% by early October 2024. Hand hygiene by food handlers after the handling of raw meat was low in July and August 2024 at 25% and 37%, respectively. After targeted interventions, compliance increased to 80% by September 2024. Conclusion: Following interventions, no additional healthcare-associated Salmonella sp cases in transplant patients were noted after July 2024. While a common source for these cases was suspected, none was definitely identified. While it was not possible to make a definitive conclusion, evidence suggests that the transplant population had a unique vulnerability to this species of Salmonella.

Introduction: Cholera disproportionately affects vulnerable populations, with outbreaks occurring mostly in locations with limited access to clean water, and adequate sanitation. Uganda experiences cholera outbreaks almost yearly, with the July -August 2023 outbreak in the central and eastern regions registering over 30 confirmed cases and 5 deaths. Cholera outbreaks are anticipated to increase especially during the rainy season, straining Uganda’s healthcare system. We implemented multimodal IPC/WaSH interventions within the affected communities and their respective Health Facilities (HFs) to control the transmission and prepare HFs to identify and manage cholera cases. Methods: Between July and August 2023, we deployed multimodal targeted interventions to deliver WaSH/ IPC interventions to health facilities (HFs) and communities in eight most affected sub-counties. We initially conducted WaSH/IPC assessments using the Ministry of health (MoH) scorecard at 31 high risk HF. At HFs, interventions focused on addressing gaps identified from the assessments including training of health workers (n=325) to improve hand hygiene, environmental cleaning, and waste elimination practices. We provided WaSH/IPC supplies to further improve practices. The assessments were repeated after the interventions, and we compared findings using a paired t-test. At community level, we trained 25 VHTs to conduct hand hygiene promotion at 6000 households within the case clustered villages. we also sensitized 500 community members at highly trafficked community sites such as fishing and markets. Results: At baseline, the mean WaSH/IPC score at HFs was 45% (Standard deviation (SD)=17.7), which improved to 72% (SD=9.9; p) Conclusion: Given the improved WaSH/IPC practices at HFs and absence of secondary transmission to other sub counties, the targeted interventions show promise for use in future cholera outbreaks in similar settings. However, with the anticipated increase in cholera outbreaks due to climate change, and the ongoing shortage of cholera vaccines, interventions that address the root causes of cholera outbreaks are increasingly important.

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

Background: Burkholderia cepacia (B. cepacia) is an aerobic, gram-negative bacilli commonly found in soil and water that has been linked to healthcare-related outbreaks. Between April 25 and September 6, 2024, four cases of B. cepacia were investigated at an acute tertiary healthcare facility. Three of the patients had undergone inpatient cardiac procedures, and the fourth patient had a tracheostomy procedure. All culture sources were collected from the respiratory tract and revealed the presence of B. cepacia. A 12-month hospital surveillance retrospective review had not previously identified this organism in our inpatient population. This investigation utilized a comprehensive approach to identify potential modes of transmission. Method: A multidisciplinary team comprised of nursing, respiratory therapy, anesthesia, and infection prevention was formed to enhance communication and identify potential gaps in infection prevention processes that may have contributed to recent cases. We concentrated on identifying potential reservoirs related to respiratory practice, with a specific focus on the use of ventilator equipment and supplies which included researching the manufacturer instructions for use (MIFU). Our investigation also included observations in the operating room and Intensive Care Unit (ICU), adenosine triphosphate (ATP) sampling of environmental surfaces, implementation of empiric contact isolation precautions in the ICU, ensuring access to alcohol-based hand sanitizer, and personal protective equipment (PPE). The four respiratory samples of B. cepacia were sent to an outside laboratory for genotyping. Results: High ATP readings in the operating rooms indicated a need for additional environmental cleaning. Issues were identified with improper use and storage of respiratory equipment which included transport ventilators, patient supplies, and anesthesia equipment. Incorrect use of PPE by perioperative and ICU staff was also observed. Genome analysis of the samples confirmed no microbiological correlation or epidemiological link (see Table 1). Conclusion: Although results indicate that internal transmission was unlikely, this investigation highlights the importance of conducting a comprehensive outbreak investigation to identify potential gaps in processes that could contribute to modes of transmission. This understanding allowed the implementation of targeted interventions to address the issues and prevent future cases.

Background: A measles outbreak associated with a migrant shelter occurred in Chicago in early 2024. Given the high transmissibility of measles in combination with the congregate nature of the shelter, health care facilities were tasked with hospitalizing patients with confirmed measles throughout the duration of their contagious period. Comer Children’s Hospital at the University of Chicago was able to hospitalize many of these patients, but numerous challenges were encountered in the initial response. Method: Communications were sent out to all providers to educate and increase awareness of measles presentations. Our infection prevention team helped coordinate timely collection of appropriate measles testing with the clinical team and helped facilitate timely processing with our microbiology lab for the test to be run by our state reference lab. Constant communication between the area hospitals and the city were instrumental in weathering the challenges our center faced in responding to the local outbreak. Result: Collaboration with the public health department allowed for optimizing turnaround times for diagnostic results, forecasting future patient volume, increasing advanced notice for patient arrival to the ED from the local shelter. Our hospital was faced with an inability to safely accommodate the influx of patients with airborne infection isolation rooms (AIIRs), and discussions with our facilities group led to the construction of multiple makeshift anterooms both in the ED and on the pediatric floors with the necessary amount of air exchanges to safely isolate these patients. A total of 18 patients were tested for measles at Comer Children’s Hospital in March 2024, including those from the community who did not reside in a shelter. Ten patients tested positive for measles, all of whom lived in the nearby shelter. Ages ranged from 2 months old to 9 years old. Patients returned back to the shelter after their infectious window was over. One patient suffered a complication of bacterial empyema requiring readmission. No exposures to patients or staff members occurred. Conclusion: Strong, efficient communication amongst hospital leaders allowed us to safely accommodate all the patients who presented with suspicion of measles. Working closely with the local public health department ensured optimal turnaround times of diagnostic results and increased our hospital’s level of preparedness.

Background: Healthcare facility-onset (HO) Methicillin-Resistant Staphylococcus aureus (MRSA) bacteremia represents a critical patient safety issue due to its associated morbidity and mortality. This metric is reportable to the Centers for Medicare and Medicaid Services (CMS) and impacts Leapfrog scores. However, the primary motivation for this investigation was to enhance patient safety by addressing opportunities for improvement identified through reporting trends. This project sought to identify root causes and implement targeted quality improvement measures to strengthen HO MRSA bacteremia prevention efforts. Method: A standardized root cause analysis (RCA) template was developed and applied across a tri-county region with nine acute care hospitals. The template included 58 variables based on local and national MRSA prevention measures and National Healthcare Safety Network (NHSN) recommendations. Cases meeting NHSN HO MRSA criteria were included in the analysis. Infection preventionists reviewed electronic medical records and documented findings using the RCA template. Abstracted data were analyzed by the hospital epidemiologist using Excel QI macros. The RCA findings highlighted gaps in peripheral intravenous line (PIV) care and maintenance as potential contributors to bloodstream infection risk. Building on these findings, a targeted nursing survey was conducted to identify barriers, gaps, and opportunities for improvement in PIV care practices, further informing the development of actionable quality improvement interventions. Result: Thirty-two HO MRSA cases were reported in 2023, 38.9% of which involved blood cultures with no other identified source. Specimen collection dates clustered around line days 4-10 and 18-22. Eighteen cases documented catheter-related issues, primarily drainage and infiltration at PIV sites. The RCA findings prompted a nursing survey to investigate PIV care practices. Survey responses revealed inconsistencies in maintenance practice, variation in documentation and monitoring, and requests for increased training and refresher sessions. These insights validated the RCA findings and informed the design of targeted interventions aimed at improving PIV care. Conclusion: HO MRSA bacteremia prevention requires a comprehensive approach that prioritizes patient safety while leveraging RCA findings and frontline staff input. The RCA findings and nursing survey have provided critical insights into gaps in PIV care and maintenance, laying the foundation for actionable quality improvement measures. Planned interventions, including re-education on PIV best practices, addressing survey-identified barriers, and implementing a bloodstream infection prevention bundle, are set for implementation in the next calendar year. These efforts aim to strengthen HO MRSA bacteremia prevention and improve patient outcomes.

Background: Despite the crucial roles Infection Preventionists (IPs) and Hospital Epidemiologists (HEs) have in the implementation of patient safety strategies, there is paucity of data on what constitutes effective IP and HE staffing. Disparities in staffing and resource allocation in IPC and HE departments are currently underexplored. This study aims to evaluate staffing patterns, resource allocation, and collaboration among IPs and HEs comparing multi-facility organizations to free standing hospitals. Methods: All IPC departments in hospitals participating in the National Healthcare Safety Network were invited to participate in an electronic survey between August and December 2023. Data were collected on hospital and IPC department characteristics including organizational structure, IP staffing and resources, as well as HE staffing and time allocation. Descriptive statistics were used to summarize the data; Wilcoxon rank-sum tests and chi-square tests were used to compare variables between single, free-standing and multi-facility hospitals. Results: Responses were received from 901 IPC departments representing 2779 NHSN facilities. The majority of respondents were situated in multi-facility (61%) vs. free-standing hospitals (39%). Over half (57%) of the IPC programs were located under Quality (65% vs. 45% for multi-facility and free-standing hospitals, respectively) and 18% under Nursing (12% vs 27% for multi-facility and free-standing hospitals, respectively). Compared to free-standing hospitals, ICP departments in multi-facility hospitals reported higher median number of IPs (3.0 vs.1.0; p) Conclusion: This study reveals differences in IPC staffing and resources between free-standing and multi-facility hospitals with free-standing hospitals facing notable challenges, including limited access to HEs/ID Physicians. Future research should focus on identifying optimal staffing models and resource allocation to address these staffing and resource disparities and ensure equitable access to expertise. Interventions that leverage the collective expertise between IPC and HE are necessary to advance patient safety.

Background: Blood culture volume is crucial to accurate diagnosis of a bloodstream infection. Underfilling blood culture bottles decreases test sensitivity and has been associated with contaminants. Pediatric blood culture volume recommendations are patient weight-based and difficult to audit. Our objectives were to assess healthcare worker pediatric blood culture volume knowledge and to measure culture volumes during the pre-implementation phase of a blood culture quality improvement program. Methods: Data were collected May 2024-November 2024. Surveys were administered to healthcare personnel who regularly obtained blood cultures. To estimate the collected blood volume, blood culture bottles in the laboratory were weighed, and weights were subtracted from the averaged weight pre-filled bottles. Bottles that were Results: <90% of the recommended weight-based volume were classified as underfilled. Blood culture results were compared between bottle characteristics using chi squared and Wilcoxon rank tests as appropriate. Results were presented to stakeholders to facilitate discussions on blood culture collection. 65 surveys were completed. 59 (90.8%) of respondents reported receiving blood culture training. Of those who received training, 51 (78.5%) reported that they had received weight-based blood culture training. A convenience sample of 1,076 bottles were weighed, representing 38.8% of blood cultures collected. Of those, 816 (75.8%) were underfilled (median percentage of recommended volume -57.8% (interquartile range (IQR) -80.3%, -12.3%)). Only 574 (54.3%) cultures were appropriately inoculated into a pediatric bottle based on patient weight. 83 bottles (7.7%) grew bacteria or fungi, 61 (73.5%) were non-commensals. There was no association between underfilling and positivity (p = 0.47). The median percentage of recommended volume did not differ between positive and negative cultures (-60.6% and -57.3%, respectively; p = 0.92). The median percentage of recommended volume for culture growing non-commensals and commensals was -55.5% and -69.1%, respectively (p = 0.01). Stakeholder groups reported that barriers to appropriate volume included: uncertainty regarding blood culture protocols, technical issues obtaining blood and total blood draw limits. Conclusions: In a large, regional children’s center, the majority of weighed pediatric blood culture bottles were underfilled despite the majority of respondents reporting blood culture volume training. Fill volume was not associated with positivity, which may be due to the large proportion of underfilled bottles in this sample. Non-commensal blood cultures did have a higher median percentage of recommended volume as compared to commensal blood cultures, which is consistent with prior publications. Future quality improvement programs will focus on dissemination of policy and addressing systems and technical barriers.

Background: Following the COVID-19 pandemic, various infection prevention strategies were implemented globally. Due to the challenges of asymptomatic transmission during the presymptomatic period, healthcare facilities in Japan adopted a strict universal masking policy for hospital staff and visitors. However, with the widespread availability of vaccines and therapeutic agents, as well as the reduced pathogenicity of the Omicron variant, particularly in younger populations, the universal masking policy was lifted for patients and visitors at our institution. This study evaluates the incidence of hospital-onset COVID-19 cases in a children’s hospital before and after this policy change. Methods: A retrospective analysis was conducted to assess hospital-onset COVID-19 cases among hospitalized patients at Tokyo Metropolitan Children’s Medical Center, Japan, between March 2020 and December 2024. Hospital-onset infection was defined as symptomatic COVID-19 diagnosed on or after the fifth day of hospitalization with a positive SARS-CoV-2 PCR result. Cases with a Ct value of ≥30, indicative of past infection, were excluded. The infection rate was calculated as the number of hospital-onset COVID-19 cases per 10,000 patient-days. During the universal masking policy period, all adults and children capable of wearing masks were required to wear them at all times in public spaces. From July 2023, patients and visitors were no longer required to wear masks unless otherwise indicated, while hospital staff continued universal masking during patient care but were allowed to remove masks for non-patient-care activities. The study compared two periods: the universal masking policy period (March 2020–June 2023) and the post-universal masking policy period (July 2023–December 2024). Results: During the universal masking policy period, there were 8 hospital-onset COVID-19 cases, compared to 10 cases in the post-universal masking policy period. The median ages of the patients were 106 months (IQR: 48-132) and 94 months (IQR: 56-152), respectively. The hospital-onset COVID-19 infection rates were 0.19 and 0.52 per 10,000 patient-days, respectively (p=0.07). None of the hospital-onset COVID-19 cases progressed to severe disease. Conclusion: The universal masking policy may have contributed to reducing the incidence of hospital-onset COVID-19 among patients and visitors in our children’s hospital to some extent. Further studies are needed to evaluate the long-term impact of masking policies on infection prevention in pediatric settings.

Background: Sars-CoV-2, better known as COVID-19, emerged in late 2019 and was declared a pandemic in March 2020. In April 2020, it was noted that multiple children were having serious inflammatory symptoms after being diagnosed with or exposed to COVID-19. The Centers for Disease Control and Prevention (CDC) defined MIS-C with a specific case definition in May 2020 that included fever, clinical severity resulting in hospitalization, evidence of systemic inflammation, involvement of at least two organ system, and no alternative plausible diagnosis. A revised case definition was issued in January of 2023 which included subjective or documented fever, clinical severity requiring hospitalization or death, elevated C-reactive protein, new onset manifestations of 2 or more organ systems, and absence of a more likely alternative diagnosis. 2023 case definition eliminates involvement of renal, respiratory or neurologic systems. Some cases reported under the original case definition would not fit the 2023 case definition. Multisystem Inflammatory Syndrome in Children (MIS-C) symptoms can include, but are not limited to, fever, red eyes, abdominal pain, nausea, vomiting, diarrhea, and organ dysfunction. Cases have varied from mild to severe. The first case of MIS-C seen at Children’s was admitted in April of 2020. Method: Diagnosing MIS-C is not always clear cut. To help with properly diagnosing cases, a multi-disciplinary team (Team) was formed to review cases regularly before reporting to the state and CDC. The team included Infection Prevention Epidemiologists, Pediatric Infectious Disease Physicians, General Pediatric Physicians, Pediatric Cardiologists, members of the Georgia Department of Public Health State Epidemiology staff, and members of the CDC staff. Results: Initially, the Team held weekly meetings to discuss cases. As cases declined in frequency, meetings were switched to bi-weekly, then monthly, and are now held ad hoc. Between April 2020 and December 2023, a total of 1339 potential cases were reviewed, and 485 cases were confirmed as meeting case definition. Of the confirmed cases, 216 required admission to an intensive care unit (ICU). Conclusion: According to CDC representatives, the number of cases reported from Children’s was significantly higher than from comparable pediatric facilities in other parts of the country. We believe this is due to the collaborative nature of our review process and our diligence in ensuring that all patients that could possibly meet definition were reviewed, regardless of clinical diagnosis. All patients were discussed to ensure a consensus was reached prior to reporting.

Background: New York City (NYC) is vulnerable to antimicrobial resistant pathogens given its population density, mobile population of travelers and immigrants, and multiple health systems in close proximity. While some NYC health systems make institutional antibiograms publicly available, it remains challenging for clinicians, antimicrobial stewardship programs, and public health institutions to understand regional antimicrobial resistance trends. Multifacility antibiograms can raise awareness of regional trends in resistance and potentially serve as a benchmark for local facilities. We created and distributed an annual regional antibiogram based on facility-level data from NYC healthcare systems. Method: Using Clinical Laboratory Standards Institute guidance, facility antibiograms for calendar years 2021, 2022, and 2023 were solicited by the NYC Health Department and voluntarily submitted by NYC healthcare systems. NYC regional antibiograms were generated for each calendar year by Firstline (Firstline.org, Vancouver, BC), a vendor with technical expertise in creating multifacility antibiograms. When sufficient data were received and facility confidentiality could be ensured, data were stratified to create additional antibiograms by facility borough, setting (i.e., emergency departments), or patient type (i.e., pediatric patients). Antibiogram data were uploaded to Firstline’s clinical decision support application for patient-facing NYC prescribers. Result: Of 56 NYC hospitals, 45 (80%) submitted antibiogram data during the project period, comprising 19,766/25,929 (76%) of NYC hospital beds. Of these hospitals, 40 (89%) submitted antibiogram data suitable for inclusion in >1 year of the citywide antibiogram (average: 31 hospitals/year). Annual antibiograms were created for Manhattan, Brooklyn, and Queens; insufficient data were received to create borough-level antibiograms for Staten Island (except 2022) and the Bronx. Annual pediatric and emergency department antibiograms were generated from citywide data. Citywide resistance rates for select pathogens and antibiotics appeared stable across the 3 years (Figure 1A-D). Antibiogram data received 417 views on Firstline between November 14, 2023–December 18, 2024. Conclusion: Through voluntary antibiogram submission from health systems, the NYC Health Department generated annual citywide antibiograms that comprised the majority of hospital beds in NYC. We achieved a high rate of voluntary participation because health systems submitted existing institutional antibiograms. Additionally, distributing the NYC antibiogram via a clinical decision support application allowed clinicians to access up-to-date citywide antimicrobial resistance rates in NYC. Despite high participation, differences in data reporting limited our ability to pool antibiograms across facilities (e.g., Figure 1B), reducing representativeness. In future antibiogram iterations, in addition to increasing facility participation, we will explore using susceptibility data electronically reported to the Health Department.

Background: The association between social determinants of health (SDOH) and healthcare-associated infections is underappreciated. We evaluated disparities in rates of candidemia associated with the social vulnerability index in Denver area census tracts. Methods: We conducted an ecologic study of the 664 census tracts within Adams, Arapahoe, Denver, Douglas, and Jefferson Counties, Colorado in 2021 and 2022. The outcome of interest was census tract rates of candidemia, with cases captured by population-based surveillance of the Centers for Disease Control and Prevention’s (CDC) Emerging Infections Program and geocoded to census tract of residence. The primary explanatory variable was the CDC and Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI) from 2022 and its four themes: socioeconomic status, household characteristics, race and ethnic minority status, and housing type and transportation. Population denominators were taken from the 2018-2022 American Community Survey, and census tract boundaries from the 2020 US Census. We used bayesian conditional autoregressive models to map smoothed rate ratios (RRs) of candidemia relative to the five-county catchment area rate and to estimate RRs and 95% credible intervals (CIs) associated with a 0.1 unit increase in SVI and each SVI theme. Analyses were conducted using SAS 9.4, RStudio 2023.06.0, and OpenBUGS 3.2.3 software. Results: Of 664 census tracts, 658 (99%) had a greater than zero population for which rates could be calculated. There were 333 candidemia cases in 5,652,254 person-years, of which 321 (96%) were geocoded and included in the analysis. Disease mapping indicated clusters of census tracts with higher than expected rates of candidemia relative to the five-county catchment area after adjusting for sex and age (Figure). For every 0.1 unit increase in census tract SVI, there was a 15% increase in the rate of candidemia (RR 1.15, 95% CI, 1.10, 1.20) after adjusting for sex and age. There were similar, modest associations with each SVI theme. Discussion: We demonstrated clustering of census tracts with higher than expected rates of candidemia and a modest association with SVI. Healthcare and public health epidemiologists should consider the contribution of SDOH to population rates of candidemia with an eye toward identifying opportunities to improve health equity.

Background: Elderly Chinese residents who live in independent living facilities are a fast-growing but under-researched population. For instance, there is a lack of research regarding the various forms of social support that Chinese residents need and the barriers to receiving social support that impact health outcomes for Chinese residents. In addition, COVID-19 adds another layer of stress to Chinese people with increased social stigma. This study aims to investigate the experiences of elderly Chinese residents in an independent living facility and the existing social support gaps. Method: 16 residents from one independent living facility were recruited. Semi-structured interviews were conducted to understand their social support needs and the gaps they experienced. Interviews were conducted in Chinese with an interviewer fluent in Chinese and English. We analyzed the data using thematic analysis based on the stress, coping, and social support gaps frameworks, which resulted in twenty-seven codes, eight subthemes, and three major themes. Results: The three main themes include: (1) Stressors based on experiences and intercultural communication challenges between healthcare providers, facility staff, and residents. Most residents are aware of their aging and risk of death through experienced or observed adverse events, including stigma and events associated with COVID-19. Communicational, cultural, and instrumental challenges during the coping and help-seeking process intensify chronic stressors in the residents’ daily lives. (2) Social support received by the residents that helps with their coping. Residents receive some level of emotional and instrumental support, with children’s support being the most complete and concrete source of support. Peer support and facility support form layers of protection for residents to maintain their health. (3) Social support gaps between residents’ needs and their received social support and associated psychological symptoms. Many residents experience helplessness and dependence on their children with their current social support experience. Passiveness in help-seeking when facing stressors is also observed. Implications: Independent living facilities with Chinese residents must ensure that their providers’ communication is culturally responsive. In addition, facilities should also prioritize communicating with family members to provide social support to Chinese residents to cope with challenges in their lives and improve their physical and mental health.

Background: Tracking and reporting antibiotic use (AU) are core elements of hospital antibiotic stewardship. However, not all hospitals have the capacity to analyze AU data. The Colorado Department of Public Health and Environment and Children’s Hospital Colorado generated two automated reports of hospital AU to support antibiotic stewardship programs (ASPs) across Colorado. Methods: The first report was an AU feedback report that summarized data from the National Healthcare Safety Network (NHSN) Antimicrobial Use and Resistance Module. Distributed twice per year, it included hospital rates of AU for high-volume and broad-spectrum antibiotics compared to rates from facilities of similar type, bed size, and geographic region (Figure). We solicited feedback from users of the AU feedback report via REDCap survey. The second report (pathway adherence) summarized adherence to treatment guidelines for adult and pediatric community acquired pneumonia (CAP), adult urinary tract infections (UTI), and adult skin/ soft tissue infections (SSTI). The pathway adherence report used self-reported, deidentified, case-level data entered by hospitals into a REDCap survey, and incorporated individualized review and expert guidance to assist ASP interventions. We analyzed all data and created custom PDFs in R-Studio and R-Markdown. Results: Between May 2023 and November 2024 we distributed 272 AU feedback reports to 52/55 (94%) acute care hospitals (ACH) and 23/33 (69%) critical access hospitals (CAH) in Colorado. Participating hospitals were distributed across the state and had a median (range) bed size of 49 (8– 828). Among 14 hospitals that provided feedback, most users said AU feedback reports included meaningful visual comparisons and helpful data quality checks. Many facilities responded that they shared the AU feedback reports with hospital leadership, pharmacists, prescribers, infection preventionists, nurses and laboratory personnel, in addition to ASPs and steering committees. In October 2024, we distributed 34 AU adherence reports to seven ACH and six CAH, including: four pediatric CAP, ten adult CAP, twelve UTI, and eight SSTI reports. Conclusion: Automated AU feedback and adherence reports were feasible, scalable, and well-received. They fostered an opportunity for public health to connect with hospital ASPs and provide 1:1 mentorship. Centrally-developed, individualized reports provide an analytic service to equip ASPs with concise, comprehensive summaries of their hospital’s AU.

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: Tuberculosis transmission in healthcare is poorly understood. Exposure definitions for patients and healthcare workers tend to be based on custom rather than data leading to many people being flagged for evaluation despite few infection transmission events. We reviewed the medical literature to identify and quantify risk factors for tuberculosis transmission in healthcare to guide risk-stratification and inform exposure definitions. Methods: We reviewed MEDLINE, EMBASE, CINAHL and Cochrane databases from inception to December 10, 2024. We included studies reporting tuberculosis transmission from infected adult patients to healthcare workers and other patients in both inpatient and outpatient settings. We evaluated 12 transmission risk factors: contact factors (exposure duration, proximity of exposure, mask use, room ventilation), patient factors (smear positivity, NAAT positivity, cavitary pulmonary disease, respiratory symptoms), and procedure factors (intubation, bronchoscopy, sputum collection, and other procedures). Results: A total of 6,695 studies were identified of which 49 met inclusion criteria. Contact factors associated with increased risk of transmission included poor room ventilation (≤ 2 air exchanges per hour, 60-70% air recirculation without high efficiency filtration, high ambient carbon dioxide levels with median 660-800 parts per million) and positive pressure air flow from poorly ventilated rooms to nearby clinical spaces. Most ventilation-related transmissions occurred before modern healthcare ventilation standards were implemented. Sustained proximity to infected patients was associated with patient-to-patient transmission via shared rooms (4 transmissions/90 exposures, minimum exposure ≥16 hours) and prolonged residence adjacent to a poorly ventilated standard pressure room (42 transmissions/430 exposures, minimum exposure ≥24 hours). Amongst 766 cases of tuberculosis transmission from patients to healthcare workers, risk factors included prolonged patient contact (median 6 hours, minimum 30 minutes), failure to wear an N95 respirator, and face-to-face patient care (28% of transmissions were associated with face-to-face patient contact, 21% of transmissions were associated with working on the same unit without direct patient contact, and contact details were unknown in 52% of transmissions). Patient factors associated with increased transmission included cavitary disease (OR 1.90, 95% CI 1.26-2.84). Transmission risk was similar for smear-positive and smear-negative patients undergoing aerosol-generating procedures without airborne precautions (17/111 smear negative exposures led to transmission vs 32/166 smear positive exposures, 15% vs 19%). All transmissions to healthcare workers associated with intubation, bronchoscopy and induced sputum collection occurred without airborne precautions. Conclusions: Detailed review of the circumstances around nosocomial tuberculosis exposure helps identify transmission risk factors that can inform more evidence-based, detailed and individualized exposure definitions.

Background: Whooping cough, caused by Bordetella pertussis (BP), is a vaccine-preventable illness spread through respiratory droplets. As the disease disproportionally impacts infants and children, vaccination is part of the routine childhood series in Canada. However, vaccine hesitancy and resultant declining rates of community immunity increase the risk of disease. We leveraged our existing wastewater-based surveillance (WBS) network to assess its ability to track clinical disease in response to an outbreak in southern Alberta. Methods: For seven months before and after the declaration of a January 2023 outbreak, wastewater samples were collected at approximately weekly intervals from five municipalities in southern Alberta (~1.05 million residents). 24-hour composite wastewater was pelleted, mechanically lysed, and DNA extracted. B. pertussis gene BP283 was quantified by qPCR and normalized against total-bacterial 16s rRNA. De-identified clinical data was obtained from Alberta Health Services (AHS) and vaccination rates collected from the AHS Interactive Health Data Application dashboard (http://www.ahw.gov.ab.ca/IHDA_Retrieval/). Per local guidelines, cases could be diagnosed through molecular testing, or if an individual had a strong epidemiological link to a known case and compatible whooping cough symptoms (https://open.alberta.ca/publications/pertussis). Cases were mapped to sewershed areas using forward sortation areas. Fishers exact test was used to determine the association of the categorical variables of positive wastewater samples and clinical cases diagnosed in the week following, as well as to compare rates of wastewater positivity before and after the outbreak was declared. Results: Over the study period 296 cases of whooping cough were identified, with 256 after the outbreak was declared. No wastewater samples were positive for BP prior to the outbreak (0%) and 22 were positive during the outbreak (19.8%), p = 0.0006 (Figure 1). Of the positives, the median ratio of BP:16s rRNA was 8.89x10-9 (IQR: 5.31x10-9 to 4.19x10-8). Detection of BP in the wastewater did not necessarily predict the occurrence of cases the following week within individual municipalities, but there was an association when all sites were aggregated (OR 2.47 [CI: 1.01–6.05], p = 0.04). Vaccination rates in the communities ranged from 40.9% to 72.2%, and did not associate with wastewater detected Bordetella pertussis. Conclusion: BP can be detected in wastewater during outbreak periods, though infrequently and in very low concentrations. For WBS to be used as an effective tool to monitor and potentially mitigate cases of whooping cough for WBS (and other respiratory pathogens which are not readily amplified in the gastrointestinal tract), assay sensitivity will need to be improved.

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: Asymptomatic bacteriuria (ASB) is common in older adults; however, its treatment in this population is not beneficial and can be harmful. We developed an intervention to update the indications on a urinalysis and urine culture order set according to recent Infectious Diseases Society of America (IDSA) guidelines recommending against testing and treatment for bacteriuria in older adults with altered mental status (AMS) or falls. Methods: This retrospective quasi-experimental study included adult patients > 65 years who presented to an Emergency Department (ED) in Southeast Texas from July 2018 to February 2024. The intervention, implemented in June 2020, included a change in the urinalysis (UA) with reflex to urine culture order set that replaced “AMS” as an indication for UA with “AMS and fever or leukocytosis” and provider education. The study’s primary outcome was whether urine studies were obtained within 24 hours of presentation to the ED. Secondary outcomes were antibiotic days of therapy (DOT) for suspected UTI, length of stay (LOS), and 30-day hospital readmission. The difference in differences (DID) technique was used to assess the impact of the intervention on older adults who presented with AMS or a fall (cases) compared to those with other chief complaints (controls). Outcomes were evaluated using multiple regression models (logistic for urinary studies ordered and readmission, linear for log LOS, and zero-inflated negative binomials for DOT) adjusted for patient demographics and comorbidities. Results: The study included 31,626 patients. Almost a third of older adult patients who presented to the ED with a fall or AMS (31.5%) received urinary testing, and 5.9% received antibiotics. 20.2% of control patients received urinary testing in the ED, and 6.3% received antibiotics. After adjusting for confounders, the intervention did not impact the percentage of tests ordered [(DID OR 1.14, 95% CI 0.93 – 1.40), (Figure 1)]. The incident rate ratio (IRR) of not receiving antibiotics was similar after the intervention (IRR 0.78, 95% CI 0.54 – 1.13), while the baseline number of antibiotics a patient received increased (IRR 1.54, 95% CI 1.05 – 2.27). Conclusions: Modifying UA indications on the urinalysis order set did not reduce testing or treatment for bacteriuria in older adults presenting with AMS or a fall. Longer-term or repetitive educational interventions could be an effective way to improve long-term stewardship outcomes in this population, especially for providers with less exposure to guidelines. Further discussion and investigation are needed.

Background: Urine cultures are the gold standard for urinary tract infection (UTI) diagnosis and are becoming increasingly important to guide antibiotic choice. However, when samples are not collected properly they can become contaminated. In our primary care safety-net clinics, 694 (55%) of all urine samples collected from non-catheterized patients were contaminated, which led to one in five patients receiving unnecessary antibiotics and a waste of lab resources. We have developed a bilingual (English and Spanish), multicultural educational intervention that includes an animated instructional video and a flyer with pictorial instructions providing step-by-step guidance for collecting a midstream clean catch (MSCC) sample. Methods: A patient advisory board (PAB) was assembled to review our materials, recruiting patient representatives from 2 private and 2 public primary care clinics in Harris County. The PAB included 7 Hispanic patients (2 female), 3 Black patients (2 female), and 2 White patients (1 female), of which half were bilingual (50%). Each board member received a urine sample collection kit plus our educational flyer. One-on-one interviews were conducted with each PAB member, during which the educational video and flyer were shown. Using thematic analysis, the interview data was condensed into themes. (Figure 1) Results: There was a lack of awareness of how to collect a MSCC among patients. Most found the educational material to be helpful in clarifying the process, and the graphical elements were especially appreciated by those with difficulty reading. Patients reported confusion around appropriate use of the wipes and lack of pictorial directions for handwashing. Physical impediments reported by patients with the MCSS process included difficulty balancing and stopping urine flow for a mid-stream sample, particularly for elderly females with medical comorbidities. Conclusions: Our educational intervention was well received by a sociodemographically diverse group of patient representatives with minimal improvements needed. Future work involves implementation of this educational intervention into primary care workflows and evaluating its effectiveness in reducing urine contamination. Acknowledgments: This work is funded by R01HS029489-02 from the Agency for Healthcare Research and Quality (AHRQ). Dr. Collazo is funded by the Department of Health and Human Services, Health Resources and Services Administration (T32HP10031).